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Pulmonary Embolism
     DR / Amany lotfy
Pulmonary embolism (PE)
 refers to the obstruction of the
 pulmonary artery or one of its
 branches by a thrombus (or thrombi)
 that originates somewhere in the
 venous system or in the right side of
 the heart
Causes
 1.thrombous
 2. embolism
 3.trauma
 4. surgery
 5. hypercoaguability
 6. heart failure
 7. pregnancy ( increase coaguability of BL
 8. older than 50 years
 9. atrial fibrillation
Pathophysiology
 -When a thrombus completely or partially
  obstructs a pulmonary artery or its
  branches,
 the alveolar dead space is increased . The
  area, although continuing to be ventilated,
  receives little or no blood flow. Thus, gas
  exchange is impaired or absent in this
  area.
Pathophysiology
 -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 reaction
 compounds (the ventilation–perfusion
 imbalance.)
Pathophysiology
 -The hemodynamic consequences are
  increased pulmonary vascular resistance
  from the regional vasoconstriction and
  reduced size of the pulmonary vascular
  bed.
 This results in an increase in pulmonary
  arterial pressure and, in turn, an increase
  in right ventricular work to maintain
  pulmonary blood flow. When
Pathophysiology
 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.
RISK FACTORS
 Venous Stasis (slowing of blood flow in
  veins)
 -Prolonged immobilization (especially
  postoperative)
 -Prolonged periods of sitting/traveling
 -Varicose veins
 -Spinal cord injury
 -Hypercoagulability (due to release of tissue
   thromboplastin after injury/surgery)
 -Injury
 -Tumor (pancreatic, GI,, breast, lung)
 -Increased platelet count (polysalathemia,
  splenectomy
RISK FACTORS

   Venous Endothelial Disease
    -

 -Thrombophlebitis    -Vascular disease
 -Foreign bodies (IV/central venous
  catheters)
 -Certain Disease States
  (combination of stasis, coagulation
  alterations, and venous injury)
 -Heart disease (especially heart failure)
 -Trauma (especially fracture of hip, pelvis,
  vertebra, lower extremities)
RISK FACTORS
 -Postoperative state/postpartum period
 -Diabetes mellitus
 -Chronic obstructive pulmonary disease c
  opD
 - Other Predisposing Conditions
 -Advanced age -Obesity -Pregnancy
 -Oral contraceptive use -Constrictive
  clothing
 -History of previous thrombophlebitis,
  pulmonary embolism
Clinical Manifestations
 1.Dyspnea is the most frequent symptom;
  tachyapnea (very rapid respiratory rate) is
  the most frequent sign . The duration and
  intensity of the dyspnea depend on the
  extent of embolization. Chest pain is
  common and is usually sudden and
  pleuritic. It may be substernal and
  misdiagnosed with angina pectoris or a
  myocardial infarction.
 - Other symptoms include anxiety, fever,
  tachycardia, apprehension, cough,
  diaphoresis, hemoptysis, and syncope.
Assessment and Diagnostic
            Findings
   -The diagnostic workup includes a
 - ventilation–perfusion scan,
 -pulmonary angiography,
 -chest x-ray
 -, ECG,
 -peripheral vascular studies, and arterial
  blood gas analysis.
 -Doppler ultrasonography and venography
Prevention
 prevent deep venous thrombosis.
 1. active leg exercises
 2. The intermittent pneumatic leg
  compression device ( reduces venous
  stasis).
 3. use of elastic compression stockings
 4. anticoagulant therapy
Medical Management
 • General measures to improve respiratory
  and vascular status
 • Anticoagulation therapy
 • Thrombolytic therapy
 • Surgical intervention
GENERAL MANAGEMENT
   -Oxygen therapy is administered to correct
  the hypoxemia, relieve the pulmonary
  vascular vasoconstriction, and reduce the
  pulmonary hypertension.
 -Using elastic compression stockings or
  intermittent pneumatic leg compression
  devices reduces venous stasis.
GENERAL MANAGEMENT
 -These measures compress the
 superficial veins and increase the
 vesecosity of blood in the deep
 veins by redirecting the blood
 through the deep veins.
 Elevating the leg (above the level
 of the heart) also increases
 venous flow.
Anticoagulation Therapy
.  Anticoagulant therapy (heparin,
  warfarin sodium)
 has traditionally been the primary
  method for managing acute deep vein
  thrombosis and PE
Anticoagulation Therapy
 Heparin is used to prevent recurrence of
  emboli but has no effect on emboli that are
  already present.
 It is administered as an intravenous bolus
  of 5,000 to 10,000 units, followed by a
  continuous infusion initiated at a dose of
  18 U/kg per hour, not to exceed 1,600
  U/hour
Thrombolytic Therapy
 -Thrombolytic therapy (urokinase, strepto-
  kinase, alteplase, anistreplase, reteplase)
  also may be used in treating
 PE, particularly in patients who are
  severely compromised (eg, those who are
  hypotensive and have significant
  hypoxemia despite oxygen
  supplementation).
-
Thrombolytic Therapy
 Thrombolytic therapy
 resolves the thrombi or emboli more
  quickly
 restores more normal hemodynamic
  functioning of the pulmonary circulation,
  Reducing pulmonary hypertension
 Improving perfusion, oxygenation, and
  cardiac output.
SURGICAL MANAGEMENT

 -Pulmonary embolectomy     requires a
  thoracotomy with cardiopulmonary by-
  pass technique.
 -Transvenous catheter embolectomy is a
  technique in which a vacuum-cupped
  catheter is introduced transvenously into
  the affected pulmonary artery. Suction is
  applied to the end of the embolus and the
  embolus is aspirated into the cup .
Nursing Management
 MINIMIZINGTHE RISK OF
  PULMONARY EMBOLISM
 PREVENTING THROMBUS
  FORMATION
 ASSESSING POTENTIAL FOR
  PULMONARY EMBOLISM
 MONITORING THROMBOLYTIC
  THERAPY
 MANAGING PAIN
Nursing management
 MANAGING  OXYGEN THERAPY
 RELIEVING ANXIETY
 MONITORING FOR
  COMPLICATIONS
 PROVIDING POSTOPERATIVE
  NURSING CARE
 PROMOTING HOME AND
  COMMUNITY-BASED CARE
 Mention nursing process of patient have
  Pulmonary Embolism ?
 DEFINE the following?
 thrombus
 Embolism
 Pulmonary vascular resistance
 -Pulmonary arterial pressure
-The intermittent pneumatic leg compression
  device
-Cardiopulmonary by pass technique
Thank you

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Pulmonary embolism

  • 1. Pulmonary Embolism DR / Amany lotfy
  • 2. Pulmonary embolism (PE)  refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart
  • 3. Causes  1.thrombous  2. embolism  3.trauma  4. surgery  5. hypercoaguability  6. heart failure  7. pregnancy ( increase coaguability of BL  8. older than 50 years  9. atrial fibrillation
  • 4. Pathophysiology  -When a thrombus completely or partially obstructs a pulmonary artery or its branches,  the alveolar dead space is increased . The area, although continuing to be ventilated, receives little or no blood flow. Thus, gas exchange is impaired or absent in this area.
  • 5. Pathophysiology  -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 reaction compounds (the ventilation–perfusion imbalance.)
  • 6. Pathophysiology  -The hemodynamic consequences are increased pulmonary vascular resistance from the regional vasoconstriction and reduced size of the pulmonary vascular bed.  This results in an increase in pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain pulmonary blood flow. When
  • 7. Pathophysiology  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.
  • 8. RISK FACTORS  Venous Stasis (slowing of blood flow in veins)  -Prolonged immobilization (especially postoperative)  -Prolonged periods of sitting/traveling  -Varicose veins  -Spinal cord injury  -Hypercoagulability (due to release of tissue thromboplastin after injury/surgery)  -Injury  -Tumor (pancreatic, GI,, breast, lung)  -Increased platelet count (polysalathemia, splenectomy
  • 9. RISK FACTORS  Venous Endothelial Disease -  -Thrombophlebitis -Vascular disease  -Foreign bodies (IV/central venous catheters)  -Certain Disease States (combination of stasis, coagulation alterations, and venous injury)  -Heart disease (especially heart failure)  -Trauma (especially fracture of hip, pelvis, vertebra, lower extremities)
  • 10. RISK FACTORS  -Postoperative state/postpartum period  -Diabetes mellitus  -Chronic obstructive pulmonary disease c opD  - Other Predisposing Conditions  -Advanced age -Obesity -Pregnancy  -Oral contraceptive use -Constrictive clothing  -History of previous thrombophlebitis, pulmonary embolism
  • 11. Clinical Manifestations  1.Dyspnea is the most frequent symptom; tachyapnea (very rapid respiratory rate) is the most frequent sign . The duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic. It may be substernal and misdiagnosed with angina pectoris or a myocardial infarction.  - Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope.
  • 12. Assessment and Diagnostic Findings  -The diagnostic workup includes a  - ventilation–perfusion scan,  -pulmonary angiography,  -chest x-ray  -, ECG,  -peripheral vascular studies, and arterial blood gas analysis.  -Doppler ultrasonography and venography
  • 13. Prevention  prevent deep venous thrombosis.  1. active leg exercises  2. The intermittent pneumatic leg compression device ( reduces venous stasis).  3. use of elastic compression stockings  4. anticoagulant therapy
  • 14. Medical Management  • General measures to improve respiratory and vascular status  • Anticoagulation therapy  • Thrombolytic therapy  • Surgical intervention
  • 15. GENERAL MANAGEMENT  -Oxygen therapy is administered to correct the hypoxemia, relieve the pulmonary vascular vasoconstriction, and reduce the pulmonary hypertension.  -Using elastic compression stockings or intermittent pneumatic leg compression devices reduces venous stasis.
  • 16. GENERAL MANAGEMENT  -These measures compress the superficial veins and increase the vesecosity of blood in the deep veins by redirecting the blood through the deep veins.  Elevating the leg (above the level of the heart) also increases venous flow.
  • 17. Anticoagulation Therapy . Anticoagulant therapy (heparin, warfarin sodium)  has traditionally been the primary method for managing acute deep vein thrombosis and PE
  • 18. Anticoagulation Therapy  Heparin is used to prevent recurrence of emboli but has no effect on emboli that are already present.  It is administered as an intravenous bolus of 5,000 to 10,000 units, followed by a continuous infusion initiated at a dose of 18 U/kg per hour, not to exceed 1,600 U/hour
  • 19. Thrombolytic Therapy  -Thrombolytic therapy (urokinase, strepto- kinase, alteplase, anistreplase, reteplase) also may be used in treating  PE, particularly in patients who are severely compromised (eg, those who are hypotensive and have significant hypoxemia despite oxygen supplementation). -
  • 20. Thrombolytic Therapy  Thrombolytic therapy  resolves the thrombi or emboli more quickly  restores more normal hemodynamic functioning of the pulmonary circulation, Reducing pulmonary hypertension  Improving perfusion, oxygenation, and cardiac output.
  • 21. SURGICAL MANAGEMENT  -Pulmonary embolectomy requires a thoracotomy with cardiopulmonary by- pass technique.  -Transvenous catheter embolectomy is a technique in which a vacuum-cupped catheter is introduced transvenously into the affected pulmonary artery. Suction is applied to the end of the embolus and the embolus is aspirated into the cup .
  • 22. Nursing Management  MINIMIZINGTHE RISK OF PULMONARY EMBOLISM  PREVENTING THROMBUS FORMATION  ASSESSING POTENTIAL FOR PULMONARY EMBOLISM  MONITORING THROMBOLYTIC THERAPY  MANAGING PAIN
  • 23. Nursing management  MANAGING OXYGEN THERAPY  RELIEVING ANXIETY  MONITORING FOR COMPLICATIONS  PROVIDING POSTOPERATIVE NURSING CARE  PROMOTING HOME AND COMMUNITY-BASED CARE
  • 24.  Mention nursing process of patient have Pulmonary Embolism ?  DEFINE the following?  thrombus  Embolism  Pulmonary vascular resistance -Pulmonary arterial pressure -The intermittent pneumatic leg compression device -Cardiopulmonary by pass technique