PE/DVT

Epidemiology the best available information suggests that there are at least 5 million
episodes of venous thrombosis annually in the United States. The annual
incidence of acute pulmonary embolism (PE) is approximately 70 per
100,000, and PE accounts for more than 200,000 hospital admissions per
year on the basis of discharge diagnosis (ICD-9) codes.

Risk factors:
1. Pregnancy, OCPs
2. Malignancy
3. Age >60
4. Hypercoagulable states
5. Cardiac disease
6. Neprotic Syndrome
7. Major surgery/ trauma

Problem 1: Vascular obstruction causes pulmonary parenchymal necrosis

Hemoptysis Weakened barrier results in bleeding into bronchioles and bronchi leading
to blood filling these low pressure environments
Blood causes irritation at pulmonary cough receptors, signal travels up
vagus nerve and elicits a motor response via the cough reflex

Problem 2: Chest Angina also can result from massive embolism representing, in this
Pain circumstance, right ventricular ischemia.

Problem 3: SOB PE causes increased PVR due to physical obstruction of vascular bed —
> hypoxic vasoconstriction in pulmonary arteries —> V/Q mismatch —
>hypoxemia

Inflammation is also thought to be responsible for stimulating respiratory

drive

Problem 4: Blood flow decreases in some area of the lung leading to increased dead
Increased work of space ( ventilation but no perfusion), resulting in hypoxemia and
breathing hypercarbia driving the respiratory effort => tachypnea

Problem 5: LE PE causes increased PVR due to physical obstruction of vascular

Edema bed. Causes hypoxic vasoconstriction within pulmonary arterial
system.
Increased PVR impedes right ventricular outflow and causes right
ventricular dilation and bowing of intraventricular septum.
Diminished flow from RV and RV dilation reduces left ventricular
 preload causing decreased CO. Causes backflow of blood causing
LE edema.

Common Blunt thoracic trauma

condition

Epidemiology >50% of non-penetrating traumas are rib fractures. Usually have

associated injuries (pneumothorax/hemothorax)

Chest pain The parietal pleura is innervated by the intercostal nerves and the phrenic
nerve. Pulmonary contusion caused by the ragged ends of the broken
bone irritate the parietal plureal and activate pain fibres in the chest wall.
Small slow conducting unmyelinated nerve sensory fibres are activated,
carry informaiton via the dorsal root ganglia. Enter the grey dorsal horn, in
the Rexed laminae regions I, IV, V and VI. Ascend 2-3 spinal cord levels
within the dorsal grey horn, and synapse onto 2nd orde rneurons. 2nd
order neurons then decussates to the contralateral lateral spinothalamic
tract and ascend to the spinal cord, brain stem, and synapse onto 3rd oter
neurons in VPL nucleus of Thalamus. Project through corona radiata to
primary somatosensory cortex (Brodmann areas 3,1,2)

Domestic Blunt trauma → Compressional force → flex and fracture ribs at weakest
violence points (ribs 4-9 most commonly fractured; posterior angle or point of
impact)

Hemoptysis Trauma to the chest can cause pulmonary contusion which is damage to
the lung parenchyma. This would result in hemoptysis as the vasculature
would be disrupted.

Hypoxia Ineffective cough → secretion retention → atelectasis → VQ mismatch

shunt → hypoxia

Lower extremity Increased pulmonary pressures from a pulmonary process would transmit
edema to the right heart and peripheral circulation creating lower extremity
edema.

Loud S2 Increased pulmonary pressures would keep the pulmonic valve open
longer which would result in a loud S2 in the pulmonic area in the 2nd
intercostal space on the left.
Dyspnea (nasal Ribs act as unit during respiration (move in AP and coronal planes) →
flaring) concerted rib motion with diaphragm and intercostal muscles helps with
inspiration (increases intrathoracic volume and decreases intrathoracic
pressure)
Neurovascular bundle (intercostal nerve, artery, vein) run along the inferior
aspect of each rib →

Diminished Splitting from the pain of a chest wall contusion or significant injury
breath sounds (pneumothorax, hemothorax, pulmonary contusion)