OUTLINE: PULMONARY EMBOLISM

I.

Definition/Types PULMONARY EMBOLISM refers to the obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart.

II.

Etiologic factors It is a common disorder and is often associated with trauma, surgery, pregnancy, heart failure, age older than 50 years, hypercoagulable states and prolonged immobility. It may also occur in apparently healthy people. a. Modifiable b. Non-modifiable

III.

Assessment a. b. c. d. Inspection Palpation Percussion Auscultation

IV.

Diagnostic and Laboratory Test Findings a. Chest X-ray-usually normal but may show infiltratrates, atelactasis, elevation of diaphragm on the affected side, or a pleural effusion. b. ECG-usually shows sinus tachycardia, PR interval depression, and non-specific T-wave changes

c.

Peripheral Vascular Studies-may include impedance plethysmography, Doppler ultrasonography or venography.

d. Arterial Blood Gas Analysis- may show hypoxemia and hypocapnia

e. Ventilation-Perfusion (V/Q) scan f. Pulmonary angiography

V.

Pathophysiology and Complications Pulmonary Embolism is due to blood clot or thrombus. However, there are other types of emboli: air, fat, amniotic fluid and septic. Although most thrombi originate in the deep veins of the legs, other sites include the pelvic vein and the right atrium of the heart. Venous thrombosis can result from the slowing blood flow secondary to damage to the blood vessel wall or changes in the blood coagulation mechanism. Atrial fibrillation can also cause PE. An enlarged right atrium in fibrillation causes blood to stagnate and form clots in this area. These clots are prone to travel into pulmonary circulation. When 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. Therefore gas exchange is impaired or absent in this area. In addition, various substances are released from the clot and the surrounding area that causes regional blood vessels and bronchioles to constrict resulting to increase pulmonary vascular resistance. This reaction compounds the ventilation-perfusion imbalance.

COMPLICATIONS
The hemodynamic consequences are increased pulmonary vascular resistance due to the regional vasoconstriction and re4duce size of the pulmonary vascular bed. This results in an increased pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain pulmonary blood flow. When the work requirement of the right ventricle exceeds 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. VI. Nursing Diagnosis VII. Treatment a. Surgical Management Surgical embolectomy It is an invasive procedure that involves removal of the actual clot and must be performed by cardiovascular surgical team with patient on cardiopulmonary Anxiety

bypass.
Transvenous catheter embolectomy A technique in which a vacuum-cupped catheter is introduced transvenously into the affected pulmonary artery.

b. Medical Management

General measures to improve respiratory and vascular status Anticoagulation therapy Thrombolytic therapy Surgical intervention

c.

Pharmacologic Management Anticoagulant therapy may be prescribed for patients who are older than 40 years of age, whose hemostasis is adequate and who are undergoing major elective abdominal or thoracic surgery to reduce the risk of postoperative DVT and PE. Heparin should be administered subcutaneously 2 hours before the surgery and continued 8 to 12 hours until the patient is discharged. 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. These are used particularly to patients who are compromised. However bleeding is a significant side effect. Contraindications include CVA within the past 1 months, other intracranial processes, active bleeding, surgery within 10 days, recent labor and delivery, trauma or severe hypertension.

d. Nursing Management VIII. Minimizing the risk of Pulmonary Embolism Assessing potential for Pulmonary Embolism Monitoring Thrombolytic therapy Managing pain Managing oxygen therapy Relieving anxiety Monitoring for complications Providing post-operative nursing care

Client Education Before hospital discharge and at follow-up visits to the clinic, the nurse instructs about preventing recurrence and reporting signs and symptoms. Most effective approach for prevention is to prevent deep venous thrombosis. a. b. c. d. e. f. g. Active leg exercises Early ambulation Use of elastic compression stockings Avoid sitting with legs crossed or sitting for prolonged periods of time Drink fluids, especially while travelling and in warm weather Do not wear constrictive clothing Legs should not be dangled while the patient sits on the edge of the bed

IX.

Reference

Guyatt GH, Akl EA, Crowther M. et al. Executive Summary: AntithromboticTherapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2suppl):7s-47s. Righini M, Le Gal G, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008;371(9621):1343-1352. Weitz JI. Pulmonary embolism. In: Goldman L, Schafer AI,eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 98. http://www.nlm.nih.gov/medlineplus/ency/article/000132.htm http://allnurses.com/pulmonary-nursing/having-trouble-nursing-187187.html http://www.patient.co.uk/doctor/Pulmonary-Embolism.htm http://en.wikipedia.org/wiki/Pulmonary_embolism http://emedicine.medscape.com/article/300901-medication#1

Risk factors for Pulmonary Embolism

VENOUS STASIS Prolonged immobilization Prolonged periods of sitting/travelling Varicose veins Spinal cord injury

HYPERCOAGULABILITY Injury Tumor Increased platelet count

VENOUS ENDOTHELIAL DISEASE Thrombophlebitis Vascular disease Foreign bodies

CERTAIN DISEASE STATES Heart disease Trauma

Postoperative state/ postpartum period Diabetes mellitus COPD