Pulmonary Embolism

Dr. Bandar AL-haguri

Assistance Professor Critical & Emergency Nursing

4th Years Nursing

2023/2024

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Definition:-
• Pulmonary embolism or PE is a sudden blockage in a lung artery.
• The blockage usually is caused by a blood clot that travels to the lung from a vein in the leg.
• PE is a serious condition that can:
✓ Damage part of lung because of a lack of blood flow to lung tissue. This damage may lead
to pulmonary hypertension .
✓ Cause low oxygen levels in the blood.
Risk Factors for pulmonary embolism: -
• Risk for PE is high in deep vein thrombosis (DVT) or a history of DVT. In DVT, blood clots form
in the deep veins of the body—most often in the legs. &, travel through the bloodstream to the
lungs, and block an artery.
• Bedridden or comatose patient.
• Having surgery or breaking a bone (the risk goes up in the weeks following the surgery or injury)
• Having certain diseases or conditions, such as a stroke, paralysis (an inability to move), chronic
heart disease, or high blood pressure
• Smoking.
Pathophysiology:
✓ Pulmonary embolism and DVT are part of a common
disease entity,
✓ Thrombus formation is frequently bilateral and often
asymptomatic.
✓ Although most thrombi form in the calf, most
pulmonary emboli (80% to 90%) arise from venous thrombi that extend into the proximal veins
(popliteal and iliofemoral) of the lower extremities Occlusion of a pulmonary artery by an
embolus produces both pulmonary and hemodynamic changes.
✓ Alveoli are ventilated but not perfused, producing areas of mismatched ventilation and perfusion.
✓ As a result, well-ventilated alveoli are underperfused and gas exchange is compromised
(increased respiratory dead space).
✓ Pulmonary vascular constriction resulting from a lack of carbon dioxide, which is normally
present in pulmonary arterial blood, shifts ventilation from the underperfused alveoli.
✓ Accompanying physiological changes include increased minute ventilation, decreased vital
capacity, increased airway resistance, and decreased diffusing capacity.

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 ✓ The severity of hemodynamic change in pulmonary embolism depends on the size of the embolus
and degree of pulmonary vascular obstruction, as well as on the preexisting status of the
cardiopulmonary system
Signs and Symptoms of Pulmonary Embolism:
Small to Moderate Embolu:
1. Dyspnea, Tachypne & Tachycardia
2. Chest pain
3. Mild fever
4. Hypoxemia
5. Apprehension
6. Cough & Diaphoresis
7. Decreased breath sounds over affected area
8. Wheezing
Massive Embolus:
A more pronounced manifestation of the above
signs and symptoms, plus the following:
1. Cyanosis
2. Restlessness & Anxiety
3. Confusion
4. Hypotension & Cool, clammy skin
5. Decreased urinary output
6. Pleuritic chest pain: associated with pulmonary infarction
7. Hemoptysis: associated with pulmonary infarction
Signs of Pulmonary Embolism in Intensive Care Patients:
1. Worsening hypoxemia or hypocapnia in a patient on spontaneous ventilation
2. Worsening hypoxemia and hypercapnia in a sedate patient on controlled mechanical
ventilation
3. Worsening dyspnea, hypoxemia, and a reduction in PaCO2 in a patient with chronic lung
disease and known carbon dioxide retention
4. Unexplained fever
5. Sudden elevation in pulmonary artery pressure or central venous pressure in a
hemodynamically monitored patient.

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Pulmonary Embolism Diagnosis:-
Medical History and Physical Exam:
Clinical evaluation may indicate a need for further studies but is not reliable for confirmation or
exclusion of the diagnosis of DVT & embolism.
Diagnostic Tests:
Many tests can help diagnose PE. Which tests you have will depend on how you feel when you get to
the hospital, your risk factors, available testing options, and other conditions you could possibly have.
You may have one or more of the following tests.
1. Ultrasound:
✓ Doctors can use ultrasound to look for blood clots in your legs.
✓ Ultrasound uses sound waves to check blood flow in your veins.
2. Computed Tomography Scans
✓ Doctors can use computed tomography scans, or CT scans, to look for blood clots in the lungs
and legs. For this test, dye is injected into a vein in arm.
✓ The dye makes the blood vessels in lungs and legs show up on x-ray images.
✓ Pt. will lie on a table, and an x-ray tube will rotate around pt. The tube will take pictures from
many angles.
3. Echocardiography (echo).
✓ This test uses sound waves to create a moving picture of heart. Doctors use echo to check heart
function and detect blood clots inside the heart.
4. EKG (electrocardiogram).
✓ An EKG is a simple, painless test that detects and records the heart's electrical activity.
5. Chest x ray.
✓ This test creates pictures of your lungs, heart, large arteries, ribs, and diaphragm (the muscle
below your lungs).
6. Chest MRI (magnetic resonance imaging).
✓ This test uses radio waves and magnetic fields to create pictures of organs and structures inside
the body. MRI often can provide more information than an x ray

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Medical Management:
✓ Administer oxygen therapy, Intubate patient, Initiate mechanical ventilation.
✓ Heparin and thrombolytic agents:
• Used to treat pulmonary embolism. However, anticoagulation with heparin is the mainstay
for treatment Low–molecular-weight heparin (LMWH).
• Treatment with heparin or LMWH should continue for at least 5 days, overlapped with
oral anticoagulation for at least 4 to 5 days
• Thrombolytic therapy is only recommended for patients with acute massive pulmonary
embolism who are hemodynamically unstable and not prone to bleeding.
✓ Treatment strategies include prevention of the recurrence of PE, facilitate clot dissolving,
reversing the effects of pulmonary hypertension, promoting gas exchange and preventing
complications.
Nursing Management:
Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of
pulmonary arterial blood flow by the embolus.
Expected outcome:
Patient maintains optimal gas exchange as evidenced by:- a. Normal arterial blood gases.
Intervention:-
- Frequently assess respiratory status including rate, depth, effort, lung sound and SPO2.
- Assess the mental status of the client (changes in orientation and behavior).
- Monitor ABGs and note changes
- Position the patient in high fowler position
- Administered oxygen as ordered by doctor
- Maintain bed rest
- Administer medications (anticoagulants) as prescribed by doctor. E.g. low-molecular-weight
heparin, warfarin etc
Managing Pain:
Chest pain, if present, is usually pleuritic rather than cardiac in origin.
- A semi-Fowler’s position provides a more comfortable position for breathing.
- It is important to continue to turn patients frequently and reposition them to improve the
ventilation–perfusion ratio in the lung.
- The nurse administers opioid analgesic agents as prescribed for severe pain.

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Managing Oxygen Therapy:
- Careful attention is given to the proper use of oxygen.
- The nurse assesses the patient frequently for signs of hypoxemia and monitors the pulse oximetry
values to evaluate the effectiveness of the oxygen therapy.
- Deep breathing and incentive spirometry are indicated for all patients to minimize or prevent
atelectasis and improve ventilation.
- Nebulizer therapy or percussion and postural drainage may be used for management of secretions.
Relieving Anxiety:
- The nurse encourages the stabilized patient to talk about any fears or concerns related to this
frightening episode,
- Answers the patient’s and family’s questions concisely and accurately.
- Explains the therapy, and describes how to recognize untoward effects early.
Monitoring thrombolytic therapy:
- The nurse is responsible for monitoring thrombolytic and anticoagulant therapy.
- Thrombolytic therapy (streptokinase, urokinase, tissue plasminogen activator) causes lysis of deep
vein thrombi and pulmonary emboli, which helps dissolve the clots.
- During thrombolytic infusion, the patient remains on bed rest, vital signs are assessed every 2
hours, and invasive procedures are limited.
- Tests to determine prothrombin time or partial thromboplastin time are performed 3 to 4 hours
after the thrombolytic infusion is started to confirm that the fibrinolytic systems have been
activated. Because of the prolonged clotting time, only essential arterial punctures or
venipunctures are performed, and manual pressure is applied to any puncture site for at least 30
minutes.
- Pulse oximetry is used to monitor changes in oxygenation.
- The nurse immediately discontinues the infusion if uncontrolled bleeding occurs
Providing Patient Education:
- Early in the patient’s hospital stay the patient and family should be taught about PE and its causes
and treatment.
- As the patient moves toward discharge.
- Teaching should focus on the interventions necessary for preventing the recurrence of deep vein
thrombosis and subsequent emboli, signs and symptoms of deep vein thrombosis and anticoagulant
complications and measures to prevent bleeding.

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Complications of pulmonary embolism:
1. Sudden cardiac death
2. Obstructive shock
3. Pulseless electrical activity
4. Atrial or ventricular arrhythmias
5. Secondary pulmonary arterial hypertension
6. Cor pulmonale
7. Severe hypoxemia
8. Right-to-left intracranial shunt
9. Lung infarction
10. Pleural effusion
11. Paradoxical embolism
12. Heparin-induced thrombocytopenia
13. Thrombophlebitis.