Pulmonary Embolism

PULMONARY
EMBOLISM
Prepared by:
RN Arpana Bhusal
BNS

Content layout
 Introduction
 Definition
 Incidence
 Types
 Risk factors
 Pathophysiology
 Clinical features
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 Diagnostic evaluation
 Management
 Emergency management
 Pharmacological management
 Surgical management
 Nursing management
 Complications
 Prevention
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Introduction
A pulmonary embolism is a potential cardiovascular
emergency where a blood clot develops in a blood vessels
elsewhere in a body( most commonly from the legs), travels to
an artery fin lungs, and forms an occlusion(blockage) of the
artery.
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Definition
 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 I
right side of the heart.
 It can damage part of the lung due to restricted blood flow,
decrease oxygen levels in the blood, and affect other organs
as well. Large or multiple blood clots can be fatal.
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Pulmonary embolism
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Incidence
 Approximately 15% patients died, causing, contributing or
accompanying in hospital related to pulmonary embolism
for the past 40 years.
 Recent large, contemporary observational studies of PE
have reported an overall 3 months mortality of 17% and an
hospital mortality of 31%when PE associated with
hypotension.
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Types
1. Thrombotic: blood
2. Non thrombotic: fat, air, tumor, amniotic fluid.
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Risk factors for Pulmonary embolism
Venous stasis (slowing of blood flow
in veins)
 Prolonged immobilization (especially
postoperative)
 prolonged periods of sitting or traveling
 varicose veins
 Spinal cord injury
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Risk factors contd…
Hypercoagulability ( due to release of tissue thromboplastin
after injury /surgery)
 Injury
 Tumor ( pancreatic, GIT, Genitourinary, breast and lung
tumor)
 Increased platelet count (polycythemia)
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Venous endothelial disease
 Thrombophlebitis
 vascular diseases
 foreign bodies (iv/central venous catheters)
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Certain disease states (combination of states,
coagulation Alterations, and venous Injury)
 Heart disease (Heart failure)
 Trauma ( Fracture of hip, pelvis, vertebra, lower
extremities)
 Post operative state /postpartum period
 Diabetes mellitus and COPD
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Other predisposing factors
 Advanced age
 Obesity
 Pregnancy
 Oral contraceptive use
 Constrictive clothing
 History of previous PE
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Pathophysiology
P.T.O
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Pathophysiology contd..
1.When an emboli travel to the lungs, they lodge in the
pulmonary vasculature.
2.The size of emboli determine the location
Blood flow is obstructed, leading to decreased perfusion of the
section of the lung supplied by the vessel.
3. The client continues to ventilate the lungs portion, but
because the tissue is not perfused, resulting in hypoxemia.
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4.If an embolus lodges in a large pulmonary vessel, it increases
proximal pulmonary vascular resistance, causes atelectasis, and
eventually reduces cardiac output.
5.The arterioles constrict because of platelet degranulation,
accompanied by a release of histamine, serotonin,
catecholamine and prostaglandins.
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6.These chemical agents result in bronchial and pulmonary
arterial constriction.
7.Vasoconstriction
8.Pulmonary embolism
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Clinical manifestations
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Clinical manifestations
 Clinical manifestations or symptoms depends on the size of
the emboli and the size and number of blood vessels
occluded. Most common manifestations are :
 DYSPNEA is the most frequent symptom
 Tachypnea (very rapid respiratory rate) is the most
frequent sign.
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Continue… ..
 Chest pain is common and is usually sudden and pleurtic in
origin.
 It may be substernal and may mimic angina pectoris
or may Myocardial infraction.
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Other symptoms include
 Anxiety
 Fever, Tachycardia, apprehension, cough,
diaphoresis, hemoptysis and syncope.
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Sign and symptoms according to size of
embolus
In massive emboli,
 Shock
 Pallor
 Severe dyspnea
 Crushing chest pain
 Pulse is rapid and weak
 Bp is low
 ECG indicates right ventricular strain
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embolus contd…
In medium sized emboli,
 Pleuritic chest pain
 Dyspnea
 Slight fever
 Productive cough with blood streaked sputum
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embolus contd…
In small emboli,
 Pulmonary hypertension
 ECG and chest X- ray indicates right ventricular
hypertrophy
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Diagnostic evaluation
 History taking
 Physical examination
 Venous studies
 Chest x-ray
 Continuous ECG monitoring
 ABGs analysis
 CBCs
 D- dimer level
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Diagnostic evaluation contd…
 Lungs scan ( ventilation and perfusion )
 Pulmonary angiography
 CT scan
 MRI
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1. History taking and physical examination
 There always needs to be a high a level of
suspicion that a pulmonary embolus may be
the cause of chest pain or shortness of
breath.
 The health care professional will take a
history of the chest pain, including its
characteristics, its onset, and any
associated symptoms that may direct the
diagnosis to pulmonary embolism
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 It may include asking about risk factors for deep vein
thrombosis.
 Coughing up blood sputum may be a sign of pulmonary
embolism.
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 Physical examination will
concentrate initially on the
heart and lungs, since
chest pain and shortness
of breath may also be the
presenting complaints for
heart attack, pneumonia,
pneumothorax
(collapsed lung),
dissection of an aortic
aneurysm, among others.
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 With pulmonary embolism, the chest examination is often
normal, but if there is some associated inflammation on
the surface of the lung , a rub may be heard.
 The surfaces of the lung and the inside of the chest wall are
covered by a membrane (the pleura) that is full of nerve
endings.
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 When the pleura becomes inflamed, as can occur in
pulmonary embolus, a sharp pain can result that is worsened
by breathing, so-called pleurisy or pleuritic chest pain.
 The physical examination may include examining an
extremity, looking for signs of a DVT, including warmth,
redness, tenderness, and swelling.
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Deep vein thrombosis
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2.D- dimer blood test
This test detects the presence of a
protein produced when a blood clot
breaks down somewhere in the body. A
negative results is a good indicator that
a clot is not present. A positive result
suggests that clots, may be present, but
more testing is needed to confirm.
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3. ABGs analysis
A sudden drop in the blood
oxygen level may suggest a
pulmonary embolism.
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4.Coagulation profile
Additional blood work should include coagulation studies to
evaluate for a hyper coagulable state, if clinically indicated. A
prolonged prothrombin time or activated partial thromboplastin
time does not imply a lower risk of new thrombosis.
progression of DVT and PE can occur despite full therapeutic
anticoagulation in 13% of patients.
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5.Chest X-rays
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Chest X-rays
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6.Lungs scan
 This test, called a ventilation perfusion scan, uses small
amount of radioactive material to study airflow( ventilation)
and blood flow ( perfusion) in the lungs.
 First, patient inhale a small amount of radioactive material
while a special camera designed to radioactive substances
records air movement in lungs.
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 Then a small amount of radioactive material is injected into
a vein via arm. Images taken after the injection show
whether patient have a normal or diminished flow of blood
to the lungs.
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7.Pulmonary angiogram
 During this test, a flexible tube
( catheter is inserted into large
vein- usually in the femoral
vein- and threaded through the
heart’s right atrium and then
into pulmonary arteries. A
special dye is injected into the
catheter, and X-rays are taken
as dye travels along the arteries
in the lungs.
 It also measure pressure in the
right side of the heart.
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8.Ultrasound
A noninvasive sonar test known as duplex venous USGs (
sometimes called duplex scan or compression ultra-
sonography) uses high-frequency sound waves to check for
blood clots in the lower limb veins.( thighs)
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9.Magnetic resonance imaging
MRI scans use radio waves and a powerful magnetic field to
produce detailed images of internal structures.
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Medical management
 Because PE is often a medical emergency, emergency
management is of primary concern. After emergency measures
have been initiated and the patient is stabilized, the treatment
goal is to dissolve the existing emboli and prevent new ones
from forming.
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Emergency management
 Massive PE is a life – threatening emergency
 The immediate objective is to stabilize the
cardiopulmonary system.
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Emergency management consists of the
following actions:-
 Oxygen is administered immediately to relive hypoxemia,
respiratory distress, and central cyanosis.
 Establish IV Lines.
 Vasopressors ,inotropic agents such as dopamine and anti
dysrhythmic agents may be indicated to support
circulation if the client is unstable.
 Perfusion scan, Hemodynamic monitoring andABG.
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Contd…
 Hypotension is treated by a slow infusions of
dobutamine.
 Continue monitoring ECG
 Blood is drawn for serum electrolytes, CBC etc
 If clinical assessment and ABG analysis indicate the
need, the patient is intubated and placed on a mechanical
ventilator.
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Contd…
 If the patient has suffered massive embolism and is
hypotensive, an indwelling urinary catheter is inserted to
monitor urinary output.
 Small doses of IV Morphine or sedative are administered to
relive patient anxiety.
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General management
 Measure are initiated to improve respiratory and vascular
status.
 Oxygen therapy
 Use of elastic compression stocking or intermittent pneumatic
leg compression devices reduces venous stasis.
 Elevating the leg above the level of heart.
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Elastic compression stocking
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Intermittent pneumatic leg
compression devices
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Treatment may include a variety of
modalities
General measures to improve respiratory and vascular
status.
 Anticoagulation therapy
 Thrombolytic therapy
 Surgical intervention
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Pharmacologic therapy
 Anticoagulation therapy: (heparin, warfarin Sodium) has
traditionally been the primary method for managing acute deep
venous thrombosis and PE.
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Pharmacologic therapy contd…
 Thrombolytic therapy: (urokinase, streptokinase, alteplase
and reteplase)
 Thrombolytic therapy resolves the thrombi or emboli more
quickly and restores more normal Hemodynamic functioning
of the Pulmonary circulation, thereby reducing Pulmonary
hypertension and improving Perfusion, Oxygenation, and
cardiac output.
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 Bleeding is a significant side effect. Contraindications to
Thrombolytic therapy include a CV
A within the past 2
months, or other active intracranial processes, active
bleeding, surgery within 10 days of the Thrombolytic
therapy, recent delivery or labor and sever hypertension.
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 Before start Thrombolytic therapy, INR. PTT ,
HEMATOCRIT,AND PLATELET counts are obtained.
 Heparin is stopped prior to administration of a
Thrombolytic therapy.
 During therapy, all but essential invasive procedure are
avoidied because of potential bleeding.
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Surgical management
 Pulmonary embolectomy
It is the emergency surgical removal of emboli which are
blocking blood circulation. It usually involves removal of
thrombi, and is then reffered to as thrombectomy.
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 Vein filter
A catheter can also be used to position a filter Vein filter. A
catheter can also be used to position a filter in the body's main
vein called the inferior vena cava that leads from your legs to
the right side of the heart.
This filter can help keep clots from being carried into lungs.
This procedure is typically reserved for people who can't take
anticoagulant drugs or when anticoagulant drugs don't work
well enough or fast enough. Some filters can be removed when
they are no longer needed.
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Nursing management
Nursing assessment
 Take history with emphasis on onset and severity of dyspnea
and nature of chest pain.
 Examine the patient leg carefully.
 Assess for swelling of leg, duskiness, warmth, pain on
pressure over gastrocnemius muscle, pain on dorsiflexon of
the foot( positive homan’s sign), which indicate
thrombophlebitis as source.
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 Monitor respiratory rate may be accelerated out of proportion
to degree of fever and tachycardia.
 Observe the rate of inspiration to expiration.
 Percuss for resonance, dullness, and flatness.
 Ascultate for friction rub, crackles, ronchi, and wheezing.
 Ascultate heart; listen for splitting of second heart sound.
 Evaluate results of PT/PTT tests for patients on
anticoagulants
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Nursing diagnosis
1. Ineffective breathing pattern related to acute increase in
alveolar dead air space and possible changes in lungs
mechanics from embolism.
2. Ineffective tissue perfusion(pulmonary) related to decresed
blood circulation.
3. Acute pain(pleuritic) related to congestion, possible pleural
effusion, possible lungs infraction.
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Nursing diagnosis contd…
4.Anxiety related to dyspnea, pain and prognosis of disease.
5.Risk for injury related to altered hemodynamic factors and
anticoagulant therapy.
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Nursing interventions
 Correcting breathing pattern
 Assess for hypoxia, headache, restlessness, apprehension,
cyanosis, behavioral changes.
 Monitor vital signs, ECG, oximetery, and ABG analysis for
oxygenation.
 Monitor patients response to IV fluids/vasopressors
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Nursing interventions contd..
 Monitor oxygen therapy used to relieve hypoxemia.
 Prepare patient for assisted ventilation when hypoxemia is
due to local areas of pneumo-constriction and abnormalities
of V/Q ratios.
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 Improving tissue perfusion
 Closely monitor for shock decreasing blood pressure,
tachycardia, cool, clammy skin.
 Monitor prescribed medications given to preserve right
ventricular filling pressure, increased BP.
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 Patient should be kept in bedrest to reduce oxygen demand
and risk of bleeding.
 Monitor urinary output hourly, because there may be
reduced renal perfusion and decreased GFR.
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 Relieving pain
 Watch patient for signs of discomfort and pain.
 Ascertain if pain worsens with deep breathing and coughing:
auscultate for friction rub.
 Give prescribed morphine, and monitor for pain relief and
signs of respiratory depression.
 Position with head of bed slightly elevated( unless
contraindicated by shock) and with chest splinted for deep
breathing and coughing.
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 Evaluate patient for sign of hypoxia thoroughly when
anxiety, restlessness, and agitation of new onset are
noted, before administering as needed sedatives.
 Consider physician evaluation when these signs are
present, especially if accompanied by cyanotic nail
beds, circumoral pallor, and increased respiratory rate.
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 Reducing anxiety
 Correct dyspnea and relief physical discomfort.
 Explain diagnostic prcedures and the patients role :correct
misconception.
 Listen to patiet concers; attentive listening relieves anxiety
and reduces emotional distress.
 Speak calmly and slowly.
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Patient education and health maintenance
 Advise patient of the possible need to continue taking
anticoagulant therapy for 6 weeks up to an indefinite period.
 Teach about the sign of bleeding, especiallyof gums, nose,
bruising, blood in urine and stools.
 For patient on anti coagulants, instruct to sue soft
toothbrush, avoid shaving with blade razor, and avois
aspirin containing products. Notify health care provider of
bleeding and bruishing.
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Patient education and health maintenance
contd..
 Warn against taking medications unless approved by health
care provider, because many drugs interact with
anticoagulants.
 Instruct patient to tell dentist about taking an anticoagulant.
 Warn against inactivity for prolonged periods or sitting with
leg crossed to prevent recurrence.
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Patient education and health
maintenance contd..
 Warn against sports/activities that may cause injury to legs
and predispose to a thrombus.
 Encourage wearing a medical alert bracelet identifying
patient on anti coagulant.
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Complications
 Cardiac arrest
 Shock
 Abnormal heart rhythms
 Pulmonary infraction
 Pleural effusion
 Paradoxical embolism
 Pulmonary hypertension
 Respiratory failure
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Prevention of Pulmonary embolism
 For patients at risk for PE, the most effective approach
for prevention is to prevent DVT (deep venous
thrombosis).
 Active leg exercise to avoid venous stasis.
 Early ambulation is necessary.
 Use elastic compression stocking.
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References
Smeltzer.S.G. Bare.B.G. Hinkle.J.G. Cheezer K.H.(2010) “Brunner &
Suddarth’s Textbook of medical- surgical nursing”.volume 1. (12th
edition).New Delhi,Kluwer India. Pvt. Ltd. 2078/03/12 at 12:00 pm
Mandal G.N (2016) “A Textbook of Medical Surgical Nursing”. 5th
edition. Kathmandu.Makalu Publication House.2078/03/11 at 4:30 pm
2019. Mayo Foundation of Medical Foundation and Research.
Pulmonary embolism. https://www.mayoclinic.org@2021/06/25at
2pm.
October 23, 2018. pulmonary-embolism.
https://www.slideshare.net/GAMANDEEP@2021/06/25 at 2pm
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