Test One Pulmonary Embolus (PE)

pulmonary embolism

clot or other material lodges in vessels of the lung

what are pulmonary emboli most often associated with?

trauma
major surgery
pregnancy
heart failure
age greater than 50
hypercoagulable states
prolonged immobility

statistics regarding PE

*AFFECTS AT LEAST 500,000 PEOPLE A YEAR IN THE U.S.,
APPROXIMATELY 10% OF WHICH DIE
*3rd LEADING CAUSE OF DEATH
*MANY DIE WITHIN 1 HR OF ONSET OF SYMPTOMS BEFORE DX MADE

What causes a pulmonary embolism?

A blockage of artery by a blood clot.

Where do PEs originate from?

long veins or pelvis
may originate in the atria

occlusion

closure of a blood vessel due to blockage

with occlusion, substances are released from the clot, what does this result in?

resulting in constriction of regional blood vessels and bronchioles

when constriction of regional blood vessels and bronchioles occurs, what does this result in?

this results in increased vascular resistance

what does the resistance and constriction result in?

this in turn increases work load of right heart

when the work load of the right heart is increased, what can this result in?

this can result in right heart failure
decrease in systemic blood pressure
and development of shock

venous stasis

the temporary cessation or slowing of the venous blood flow

risk factors for venous stasis

prolonged immobilization
prolonged periods of sitting
varicose veins
spinal cord injury

Hypercoagulability

increased ability of the blood to coagulate

coagulate

to thicken, clot

risk factors for hypercoagulability

*injury
tumor (pancreatic, gastrointestinal, genitourinary, breast, lung)
increased platelet count (splenectomy, polycythemia)

disease risk factors for PE

heart disease
trauma
postop/postpartum
stroke
diabetes mellitus
COPD

other risk factors for PE

obesity
pregnancy
oral contraceptive use
constrictive clothing
hx of DVT or PE
Smoking

SUBMASSIVE Signs and symptoms of PE

Dyspnea
Tachypnea
Tachycardia
Chest Pain
Apprehension
Mild Fever
Hypoxemia
cough
diaphoresis
decreased breath sounds over affected area
rales
wheezing

rales

Crackles; wet crackling noise in lungs during inspiration

pleuritic type chest pain

sharp stabbing pain on inspiration, dry cough

MASSIVE PE signs and symptoms

More severe mani- festations of S&S
Cyanosis
Restlessness
Anxiety
Confusion
Decreased urine output
Cool, clammy skin
Hypotension/Shock
Hemoptysis
Pulmonary hypertension
Elevated pulmonary artery pressures
Signs of acute right heart failure
Distended neck

pulmonary hypertension

elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles.

Hemoptysis

coughing up blood

arterial blood gases

clinical test on arterial blood to identify the levels of oxygen and carbon dioxide

what can ABGs and pulse oximetry reveal?

ABG studies and pulse oximetry may reveal hypoxemia but are not sufficient to make the diagnosis of PE.

assessment findings with a PE

abrupt
fearful, apprehensive, with a feeling of impending doom
increased restlessness

what may a patient have a history of?

history of leg pain especially in calf or knee area
indwelling IV
traveled recently with prolonged sitting
had a blood clot before
had recent surgery
ever been on anticoagulants
given birth or is on contraceptives
smokes
sedentary life style

diagnosis of PE

Chest x-ray usually
Ventilation-perfusion Scan (Ventilation Perfusion Scan (V/Q Scan)
A negative V/Q scan r/o PE
An inconclusive scan warrants pulmonary angiography: Specific
& Definitive Test
Spiral CT is now being done to non-invasively DX PE

Ventilation-perfusion Scan

a scan that tests whether a problem in the lungs is caused by airflow (ventilation) or blood flow (perfusion)

spiral ct

a method of processing computerized tomography data to provide rapid, three-dimensional images of internal organs

pulmonary angiography

special X-rays of the vessels of the lungs.

Fat embolism syndrome

occurs when fat enters the blood stream

what is fat embolism often preceded by?

long bone fracture

principle clinical features of FES?

respiratory failure, cerebral dysfunction, and petechiae

petechiae

small, pinpoint hemorrhages

respiratory failure

The reduction of breathing to the point where oxygen intake is not sufficient to support life

discuss the mechanical theory of FES

FES results from physical obstruction of the pulmonary and systemic vasculature with embolized fat.

discuss the biochemical theory of FES

Circulating free fatty acids are directly toxic to pneumocytes and capillary endothelium in the lung, causing interstitial hemorrhage that can result in vascular injury and ARDS

pneumocytes

cells lining the alveoli of the lungs

goals of treatment of ARDS

Increase alveolar gas exchange
Improve pulmonary perfusion
Eliminate emboli
Prevent complications.

treatment of PE

Oxygen Therapy:
- May need mechanical ventilation
-Less severe cases, oxygen by mask or NC
Remove clot
Thrombolytic therapy with lysing agent such as TPA
Surgical intervention with embolectomy
Insertion of Vena Cava Filter (Greenfield Vena Cava Filter)
Co

ECHMO

a treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream

What is ECHMO used specifically for?

puts oxygen into the blood and takes out carbon dioxide just like our lungs do.

What should be monitored during treatment of PE

Vital signs
Lung Sounds
Cardiac monitoring
Respiratory status
Neuro Status
Pulse ox

What type of BP support may be needed in treatment of PE?

inotropic agents such as dopamine

target INR

2-3

Heparin

Anticoagulant

warfarin

Anticoagulant

prevention of PE

ambulating patients
turning
applying pneumatic stockings
avoiding prolonged sitting
being vigilant about central venous catheter removal
frequent physical assessment
leg exercises
anticoagulants