Pulmonary embolism occurs when a blood clot or foreign material blocks one of the pulmonary arteries in the lungs. It can be caused by deep vein thrombosis, when a blood clot forms in the deep leg veins or pelvis and travels to the lung. Risk factors include immobility, recent surgery, cancer, and estrogen-containing medications. Symptoms may include chest pain, difficulty breathing, and a rapid heart rate. Diagnosis involves blood tests, imaging like CT scans, and pulmonary function tests. Treatment focuses on blood thinners to prevent further clots and dilation of existing clots, as well as oxygen, medications, and occasionally clot-busting drugs to restore lung function and relieve symptoms.

1. PulmonaryPulmonary
embolism- -
NURSING Critical Care
respiration - lecture 1
Prepared & Designed BY :
dr.hind alassaf

2. Definition of Pulmonary embolism PE :
Thrombus or non thrombus clotting in pulmonary arterial system, disrupting
the blood flow to region of the lung.
Type of thrombus that cause PE :
1. Major thrombus arises from deep leg veins as (iliac, femoral, popliteal
and pelvic vein) or upper extremities or right ventricle.
2. Non thrombus arises from (tumor, amniotic fluid, air and foreign body).

3. Predisposing factors :
• Venous stasis (atrial fibrillation - decreased cardiac output - immobility).
• Injuries of vascular endothelium most common (local vessel injury -
infection - incision - atherosclerosis).
• Hypercoagulability as in polycythemia.
Precipitating factors :
✦ Previous pulmonary embolus.
✦ Cardiovascular disease (heart failure, Rt ventricular infarction,
cardiomyopathy, cor pulmonale).
✦ Surgery (orthopedic, vascular, abdominal).
✦ Cancer (ovarian, pancreatic, stomach, extrahepatic bile duct system).
✦ Traumatic injury or burn (lower extremities, pelvis and hips)
✦ Gynecological status (pregnancy, postpartum, birth control pills, estrogen
replacement therapy).
Causes and risk factors of Pulmonary embolism ?

4. Pathophysiology :1.Increase dead space :
Occurs when an area of the lung is receiving ventilation without being
perfused. The ventilation to this area is known as wasted ventilation,
because it doesn’t participate in gas exchange, leading to increase
work of breathing and broncoconstriction.
2. Broncoconstriction :
Due to alveolar hypocarbia, hypoxia and release of mediators.
Broncoconstriction promotes development of atelectasis.

5. 3. Compensatory shunt :
Occurs because the unaffected areas of the lungs have to accommodate
cardiac output. So, perfusion exceed ventilation and blood return to the left
side heart without having participated in gas exchange leading to hypoxemia.
4. Homodynamic consequences :
Pulmonary hypertension, vasoconstriction and increase pulmonary vascular
resistant, increase pulmonary artery pressure.
Right ventricular failure occurs leading to :
‣ Decrease left ventricular preload.
‣ Decrease cardiac output.
‣ Decrease blood pressure followed by shock.

6. Clinical manifestation :
• Tachycardia &Tachypnea
• Dyspnea & chest pain.
• Fever.
• Cough.
• Syncope.
• Hemodynamic instability.

7. Diagnosis :✦ ABGs : Hypoxemia and respiratory alkalosis (low PaCo2 -
high PH).
✦ D-dimmer : found elevated.
✦ ECG : tachycardia, S wave in lead І, and q wave with inverted t wave in lead
Ш, atrial fibrillation , RBBB, T wave inverted in anterior or inferior lead.
✦ Chest x-ray : cardiomegaly, pleural effusion, elevated diaghragm, enlargement
of right descending pulmonary artery (Palla’s sign), atelectasis.
✦ Echocardiography : transthoracic, transesophageal visualization VQ scintigraphy,
pulmonary angiography, DVT study , CT.

8. (A) CT angiography of the chest using a pulmonary
embolism protocol shows a filling defect in the pulmonary
artery to the lateral basal segment of the right lower lobe
(white arrow).
(B) A wedge-shaped peripheral consolidation (black
arrowhead) was identified more peripheral to the
previously described filling defect, producing the
Hampton’s hump seen on radiography.
Frontal radiograph of the chest shows a peripheral wedge-shaped
opacity ( without air bronchograms ) at the lateral right lower lobe
(black arrow).

9. Medical management :
1.prevention of recurrence :
✦ Administer unfractionated heparin or low molecular heparin and walfarin (Coumadin).
✦ Heparin administered and given to prevent further clot from forming (aPTT should be
maintained 2-3 times of the upper normal level).
✦ Heparin has no effect on the existing clot.
✦ Walfarin should be started at the same time, and given to maintain INR between 2-3
and patient continued walfarin 3-12 months.
✦ Heparin discontinued if INR reached 3.
✦ A percutaneous venous filter (Greenfield filter) is placed into the inferior vena cava to
prevent further thrombotic emboli from migrating into the lungs. This filter is used in :
- Patients whom anticoagulation is contraindicated.
- Patients who still have clot despite normal therapeutic drug level or unable to achieve
normal drug level.

10. 2.Colt dissolution :
✦ By giving fibrinolytic therapy as rtPA or STK, the therapeutic window within 14 days
of diagnosis.
✦ Surgical embolectomy ( considered last restore to remove the clot).
3.Reversal pulmonary hypertension :
✦ Administer inotropic agent and fluid.
✦ Fluid given to increase right ventricular preload and stretch right ventricle to
increase contractility.
✦ Inotropic agent given to increase contractility and cardiac output.

11. Nursing intervention :
1.Prevent develop of DVT :
✦ DVT is the major cause of pulmonary embolism
✦ DVT is produced as a complication of immobility
✦ patient should :
- Use graduated compression stocking.
- Do passive or active range of motion.
- Take adequate hydration.
- Practice progressive ambulation.
2.Optimize oxygenation :
✦ Position the patient to Prevent desaturation.
✦ Promoting secretion clearance.
3.Monitor bleeding :
✦ The patient receive fibrinolytic therapy should be observed for signs of
bleeding, so the gums, skin, urine, stool and emesis should be observed.
✦ Monitor aPTT and INR.

12. 4.Patient education :
✦ Pathophysiology of disease.
✦ Specific cause.
✦ Precipitating factor modification.
✦ Importance of stop smoking.
✦ Measures to prevent deep vein thrombosis as :
• Avoid tight fitting clothes.
• Avoid crossing legs.
• Avoid prolonged sitting or standing.
• Elevate legs when sitting.
• Ambulation and exercise.
✦ Signs and symptoms of deep vein thrombosis (e.g, redness, swelling, sharp or
deep leg vein).
✦ Importance of taking medications.
✦ Signs and symptoms of anticoagulant complications (e.g., excessive bruising,
discoloration of the skin, change in color of urine or stool).
✦ Measures to prevent bleeding (use soft bristle toothbrush caution when shaving).

13. Nursing diagnosis :
1. Impaired gas exchange related to V/Q mismatch or intrapulmonary shunt.
2. Acute pain related to transmission and perception of cutaneous, visceral, muscular,
or ischemic impulses.
4. Risk for aspiration.
5. Anxiety related to threat to biologic, psychological or social integrity.
7. Powerlessness related to lack of control over current situation or disease progression.
8. Compromised family coping related to critically Ill family member.
10.Knowledge deficit related to lack of previous exposure to information.

14. Summary of the lecture in video :
1. https://youtu.be/09nOkbuXlUY
2. https://youtu.be/0PEhvACEROI

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