Pulmonary Embolism (Pe)

Front 1

Pulmonary Embolism (PE)

Back 1

-Blockage of a pulmonary artery by thrombus, fat or air emboli and tumor tissue
-Most common pulmonary complication of hospitalized clients
-50,000 die from PE each year
-650,000 have nonfatal PE's

Front 2

Etiology

Back 2

-Most PE's arise from thrombi in the deep veins of the legs (from upper extremities is rare)
-Presence of a DVT is often not suspected until a PE occurs
-Develop from thrombi mobile clots that generally do not stop moving until they lodge in a narrow part of the circulatory system
-Other sites of origin include: right side of heart (afib), pelvic vein (after childbirth or surgery), fat emboli (fractured long bones), air emboli (IV's), bacterial vegetation, amniotic fluid, and tumors.

Front 3

Clinical Manifestations

Back 3

-Anxiety -- impending sense of doom
-Sudden onset of unexplained dyspnea, tachypnea, or tachycardia
-Cough, pleuritic chest pain, hemoptysis, crackles, fever
-Sudden changes in mental status
-Massive PE may produce sudden collapse of the client with shock, pallor, severe dyspnea and crushing chest pain. The pulse is rapid and weak and BP is low.
-Death in 60% of patients with massive emboli

Front 4

Complications

Back 4

-Death
-Pulmonary Infarction
-Pulmonary Hypertension

Front 5

Pulmonary Infarction

Back 5

-Death of lung tissue
-Leads to alveolar necrosis and hemorrhage
-Dead tissue can become infected and abscess (pleural effusion)

Front 6

Pulmonary Hypertension

Back 6

-Occurs when >50% of the normal pulmonary bed is compromised
-Dilation and hypertrophy of right ventricle (cor pulmonale) leads to left-sided heart failure
-Signs of right-sided heart failure (jugular vein distention, peripheral edema)

Front 7

Diagnostic Studies

Back 7

-VQ Scan: Perfusion and Ventilation
-D-Dimer
-Pulmonary Angiography if VQ scan is inconclusive
-Spiral CT

Front 8

VQ Scan

Back 8

-Perfusion Scanning - involves IV injection of a radioisotope - A scanning device detects the adequacy of the pulmonary circulation
-Ventilation Scanning -- Involves inhalation of a radioactive gas -- *Requires cooperation of the client

Front 9

D-Dimer

Back 9

-Reccommended when PE is initially suspected
-Degradation product of fibrin
-Normal D-Dimer can rule out PE
-If elevated, a venous study is indicated to look for DVT
-If DVT is located, PE is likely and anticoagulation therapy should be started
-Patients with increased D-Dimer but normal venous ultrasound require a lung scan (VQ)

Front 10

Pulmonary Angiogram

Back 10

-If lung scan (VQ) is inconclusive
-Invasive procedure that involves the insertion of a catheter through the antecubital or femoral vein, advanced to the pulmonary artery, and injection of contrast media
-Allows visualization of pulmonary vascular and
-location of the embolus
-*Alert -- IV dye allergy (dye allergies and renal function need to be considered)

Front 11

Spiral CT

Back 11

-Diagnostic tool of choice
-Relatively new noninvasive diagnostic test
-Obtains continuous slices allowing visualization of the entire lung
-The data can be computer reconstructed to allow for a 3D picture of the area to assist in emboli visualization

Front 12

ABG - Arterial Blood Gases

Back 12

-Important
-Non-diagnostic
-PAO2 low secondary to inadequate oxygenation secondary to occluded pulmonary vasculature
-PCO2 is low because of hyperventilation
-PH increases secondary to low PCO2

Front 13

Objectives of treatment

Back 13

-Prevent further growth of thrombi in the lower extremities
-Prevent embolization from the upper or lower extremities to the pulmonary vasculature
-Provide cardiopulmonary support if indicated

Front 14

Treatment -- Medical

Back 14

-#1! Keep on bed rest in semi-fowlers position or higher
-O2
-TPA fibrinolytic
-Anticoagulation with heparin and coumadin
-Turn, cough, deep breath
-Digoxin/diuretics (if heart failure is present)
-Pain control with narcotics

Front 15

Anticoagulation

Back 15

-Heparin and coumadin are the anticoagulant drugs of choice
-Heparin started immediately and continued until the patient is therapeutic on coumadin
-Heparin is adjusted according to PTT
-Coumadin is adjusted according to INR

Front 16

IV Heparin

Back 16

-Check the order
-Obtain an infusion pump
-Check the patient's IV site
-Obtain the heparin and the tubing
-*What lab values do you need to know before starting the heparin??? (PTT, Platelets, INR)

Front 17

Deliver 1000 units per hour of IV heparin
Available is 25,000 units in 500 mL of D5W
Calculate mL/hr

Back 17

mL=500mL/25,000 units X 1000 units/hr = 500,000/25,000 = 20 mL/hr

Front 18

IV Heparin

Back 18

1. Set up concentration in mL/units
2. Set up mL/hr
3. Determine mL/hr

Front 19

Thrombolytic Therapy

Back 19

-Agents such as TPA (tissue plasminogen activator) dissolve PE's and the source of thrombus in the pelvis or deep leg veins
-Decrease the chance of recurrent PE's
-Many contraindications (chapter 33)
-Risk of bleeding (much greater than heparin or coumadin)

Front 20

Circulatory Support

Back 20

-Vasopressor agents may be necessary to support systemic circulation (increase BP)
-Digitalis and diuretics are used if heart failure is present

Front 21

Treatment -- Surgical

Back 21

-Embolectomy
-Intracaval filter devices (IVC's) to prevent further pulmonary embolism

Front 22

Pulmonary Embolectomy

Back 22

-If pulmonary arterial obstruction is severe (>50%), and patient does not respond to conservative therapy
-Rarely performed
-High mortality rate
-Pre-op pulmonary angiography is necessary to identify and locate the site of the embolus (must know exact location of PE)

Front 23

Health Promotion

Back 23

-Risk factors parallel those for DVT (Table 37-7 Lewis)
-Prevention measures are the same as for the prophylaxis of DVT

Front 24

Analysis/Diagnosis

Back 24

Actual:
-Impaired gas exchange
-Ineffective breathing pattern
-Anxiety

Front 25

Analysis/Diagnosis (cont)

Back 25

Risk for ineffective therapeutic regime management
Potential Complications:
-PC:Hypoxemia
-PC:Impaired Tissue Perfusion
-PC:Decreased Cardiac Output
-PC:Bleeding

Front 26

Acute Implementation

Back 26

-Bed rest in semi-fowlers postion or higher
-IV for meds and fluid therapy
-Monitor for side effects of meds
-O2 therapy as ordered
-Careful monitoring of vital signs, O2 sats, EKG, ABG's, and lung sounds
-Emotional support to decrease anxiety

Front 27

Home Care

Back 27

-Treatment of underlying chronic diseases: diabetes, Afib, Obesity etc.
-Similar to that for the patient with DVT
-Discharge planning aimed at preventing complications and recurrence
-Reinforce regular follow-up care/INR monitoring
-Teaching Guide Table 37-14 Lewis

Front 28

Evaluations/Expected Outcomes

Back 28

-Adequate tissue perfusion and respiratory function
-Adequate cardiac output
-Increased level of comfort
-Absence of recurring PE/DVT
-Absence of bleeding

Front 29

Current Trends

Back 29

-Multislice Spiral CT scans are now becoming available that can collect even more data (more slices) than previous systems
-Increased public awareness
-Arixtra SC once daily for the treatment of stabe patients with PE
-Home self-monitoring of INR

Front 30

Pleural Effusion

Back 30

Fluid in the thoracic cavity between the visceral and parietal pleura. It may be seen on a chest radiograph if it exceeds 300 mL

Front 31

cor pulmonale

Back 31

Hypertrophy or failure of the right ventricle resulting from disorders of the lungs, pulmonary vessels, or chest wall.
Signs of right-sides heart failure (jugular vein distention, peripheral edema)