10/24/2020

PULMONARY EMBOLISM

C
B PE

D
Figure 20
20--1. A, Pulmonary embolism (PE). Bronchial smooth muscle constriction (B), atelectasis (C),
and alveolar consolidation (D) are common secondary anatomic alterations of the lungs.

LEARNING OUTCOMES
At the end of this lecture, students will be able to:

Describe Pulmonary embolism (PE) , its pathophysiological

changes, and discuss its clinical manifestations.

Identify the diagnostic test that may be used to diagnose

Pulmonary embolism (PE) .

Discuss the medical and nursing management of Pulmonary

embolism (PE) .

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INTRODUCTION

Pulmonary embolism (PE) is an obstruction of the pulmonary

artery or one of its branches by a thrombus (or thrombi)
that originates somewhere in the venous system.

PE is often associated with trauma, surgery (orthopedic),

pregnancy, heart failure, age > 50 years, hypercoagulable
states, and prolonged immobility.

Most thrombi originate in the deep veins of

the legs; other sites include the pelvic veins
and the heart’s right atrium.

An enlarged right atrium in fibrillation

causes blood to stagnate and form clots that
may travel into the pulmonary circulation
causing PE.

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ETIOLOGY

Blood clots—most common source of pulmonary emboli

 Most originate from deep veins in the lower part of the
body, i.e., leg veins
Other possible causes
 Fat
 Air
 Amniotic fluid
 Bone marrow
 Tumor fragments

RISK FACTORS

Venous stasis
 Prolonged bed rest
 Prolonged sitting
 Congestive heart failure
 Varicose veins
 Thrombophlebitis
Trauma
 Bone fractures
 Extensive injury to soft tissue
 Postoperative or postpartum states
 Extensive hip or abdominal operation


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RISK FACTORS
Hypercoagulation disorders
 Oral contraceptives
 Polycythemia ( increase of HB concentration related to
decrease plasma or increase RBC)
 Multiple myeloma
Others
 Obesity
 Malignant neoplasm
 Pregnancy
 Burns
 Smoking

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PATHOPHYSIOLOGY

When there is a complete or partial obstruction

of a pulmonary artery or its branches by a
thrombus, the alveolar dead space is increased.
The area, although continuing to be ventilated,
receives little or no blood flow, resulting in
impaired or absent gas exchange.
.
١٠

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In addition, various substances are released

from the clot and surrounding area, causing
regional blood vessels and bronchioles to
constrict. This causes an increase in pulmonary
vascular resistance. This results in an increase in
pulmonary arterial pressure and, in turn, an
increase in right ventricular work to maintain
pulmonary blood flow.
١١

• When the work requirements of the right

ventricle exceed its capacity, right
ventricular failure occurs, leading to a
decrease in cardiac output followed by a
decrease in systemic blood pressure and
the development of shock

١٢

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Alveolar dead space: A well-ventilated part of the lung is not

receiving blood flow. The air reaching that region of the lung is
therefore wasted since it cannot participate in gas exchange, thus the
alveoli are considered dead. ١٣

١٤

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CLINICAL MANIFESTATIONS
The symptoms of PE depend on the size of the
thrombus and the area of the pulmonary artery occluded
by the thrombus.

Dyspnea is the most frequent symptom; while

tachypnea is the most frequent sign. Chest pain is
common and is usually sudden and pleuritic. Other
symptoms include anxiety, fever, tachycardia,
apprehension, cough, diaphoresis, hemoptysis, and
١٥
syncope.

• Deep venous thrombosis is closely

associated with the development of PE.
Typically, patients report sudden onset of
pain and/or swelling and warmth of the
proximal or distal extremity, skin
discoloration, and superficial vein
distention.
١٦

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١٧

COMPLICATIONS OF PULMONARY EMBOLISM

• Acute Respiratory failure

• Acute Respiratory Distress Syndrome(ARDS)

• Cardiogenic Shock

• Pulseless Electrical Activity (PEA)

• Pulmonary Hypertension

١٨

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١٩

PULMONARY EMBOLUS: HEALTH PROMOTION AND

ILLNESS PREVENTION

• Stop smoking
• Reduce weight
• Increase physical activity
• If traveling or sitting for long periods, get up
frequently and drink plenty of fluids
• Refrain from massaging or compressing leg muscles

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• Prevention of PE begins with prevention of

DVT
Sequential compression devices
Early ambulation
Prophylactic use of anticoagulant medications

٢١

ASSESSMENT AND DIAGNOSTIC FINDINGS

Early recognition and diagnosis of PE are

priorities as death commonly occurs within
One hour of symptoms.

If lung scan results are not definitive,

pulmonary angiography is the gold standard
for the diagnosis of PE.

٢٢

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• The diagnostic workup includes a ventilation–

perfusion scan, pulmonary angiography, chest x-
ray (may show infiltrates, atelectasis, elevation of
the diaphragm on the affected side, or a), ECG
(pleural effusion, sinus tachycardia, PR interval
depression, and nonspecific T-wave changes), and
arterial blood gas analysis (may show hypoxemia
and hypercapnia (from tachypnea)).
٢٣

FIGURE 20-4. A RIGHT VENTRICULAR LIFT CAN BE DETECTED IN PATIENTS WITH A

PULMONARY EMBOLISM IF SIGNIFICANT PULMONARY HYPERTENSION IS PRESENT.

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MEDICAL MANAGEMENT
Emergency management.
Nasal oxygen to relieve hypoxemia, respiratory
distress, and central cyanosis.
Intravenous infusion lines to administer medications or
fluids.
A perfusion scan, arterial blood gas determinations are
performed. Pulmonary angiography may be performed.
Hypotension is treated by a slow infusion of
dobutamine (Dobutrex). ٢٥

The ECG is monitored continuously for

dysrhythmias which may occur suddenly.
Digitalis glycosides, intravenous diuretics, and
antiarrhythmic agents may be indicated.
Blood is drawn for serum electrolytes and
complete blood count.
Intubation and mechanical ventilation may be
performed based on clinical assessment and
arterial blood gas analysis.
٢٦

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Emergency management (Continued…).

In case of hypotension, a Foley’s catheter is inserted to
monitor urinary output.
Small doses of intravenous morphine to relieve the
patient’s anxiety, to alleviate chest discomfort, to
improve tolerance of the endotracheal tube, and to ease
adaptation to the mechanical ventilator.
Intubation & mechanical Ventilation

٢٧

Pharmacologic therapy. (Anticoagulation)

Heparin is used to prevent recurrence of emboli.
The dose is an intravenous bolus of 5,000 to
10,000 units, followed by a continuous infusion at
a rate of 18 U/kg per hour. The rate is reduced in
patients with a high risk of bleeding. Heparin is
usually administered for 5 to 7 days.

٢٨

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• Warfarin sodium administration is begun within 24

hours after initiation of heparin therapy because its
onset of action is 4 to 5 days. Warfarin is usually
continued for 3 to 6 months. Anticoagulation therapy
is contraindicated in patients who are at risk for
bleeding (eg, those with gastrointestinal conditions or
with postoperative or postpartum bleeding).

٢٩

Streptokinase may be used in patients who are

hypotensive and have significant hypoxemia. It
resolves the thrombi or emboli more quickly and
reduces pulmonary hypertension and improves
perfusion, oxygenation, and cardiac output.
Is initiated after stopping heparin. During therapy, all
but essential invasive procedures are avoided because
of potential bleeding.
٣٠
Cessation necessitates the initiation of anticoagulants.

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SURGICAL MANAGEMENT

• Embolectomy
• Inferior vena cava filter

٣٢

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NURSING MANAGEMENT FOR THE PATIENT

WITH PULMONARY EMBOLISM
1. Preventing thrombus formation

2. Monitoring thrombolytic therapy

3. Providing post operative nursing care

4. Managing O2 therapy

5. Preventing anxiety

6. Monitor for complications

Preventing Thrombus Formation. The nurse:

encourages ambulation and active and passive leg
exercises to prevent venous stasis in patients on bed rest
and to help increase venous flow.
discourages the patient against sitting or lying in bed
for prolonged periods, crossing the legs, and wearing
constricting clothing. Legs

٣٤

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Discourages legs dangling or feet placed in

a dependent position while sitting on the
edge of the bed; instead, the patient’s feet
should rest on a chair.
Should not leave intravenous catheters in
place for prolonged periods.

٣٥

Assessing Potential For Pulmonary Embolism. The nurse

should:
 Examine patients who are at risk for developing PE for a positive
Homans’ sign (pain in the calf as the foot is sharply dorsiflexed), which
may or may not indicate impending thrombosis of the leg veins. A
positive Homans’ sign may indicate DVT.

٣٦

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Monitoring Thrombolytic Therapy.

keeps the patient on bed rest
assesses vital signs Q2H.
uses pulse oximetry to monitor changes in oxygenation.
immediately discontinues the infusion if uncontrolled
bleeding occurs.

٣٧

Ensures that 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.
Ensures that only essential venipunctures are
performed because of the prolonged clotting time, and
manual pressure is applied to any puncture site for at
least 30 minutes.

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NURSING MANAGEMENT
Minimizing The Risk of Pulmonary Embolism
A major responsibility of the nurse is to identify patients
at high risk for PE and to minimize the risk of PE in all
patients. Therefore, the nurse must give attention to
conditions predisposing to a slowing of venous return
(i.e. prolonged immobilization, prolonged periods of
sitting/traveling, varicose veins, spinal cord injury),

٣٩

• Hypercoagulability due to release of tissue

thromboplastin after injury/surgery (i.e.
pancreatic, GI, GU, breast, or lung tumor,
increased platelet count in polycythemia),
venous endothelial disease (i.e.
thrombophlebitis, foreign bodies such as
IV/central venous catheters)

٤٠

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Managing Chest Pain

Places the patient in a semi-Fowler’s position which is
more comfortable for breathing.
continues to turn the patient frequently and
repositioning him to improve the ventilation–perfusion
ratio in the lung.
Administers opioid analgesics as prescribed for pain.

٤١

Managing Oxygen Therapy

Gives careful attention the proper use of oxygen and
ensures that the patient understands the need for
continuous oxygen therapy.
Assesses the patient frequently for signs of hypoxemia
and monitors the pulse oximetry values to evaluate the
effectiveness of the oxygen therapy.
encourages deep breathing and performs incentive
spirometry to minimize or prevent atelectasis and
٤٢
improve ventilation.

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Managing Anxiety
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.

٤٣

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