Pulmonary Embolism Pulmonary Embolism DR / DR / Amany lotfyAmany lotfy

Pulmonary embolism (PE)Pulmonary embolism (PE)

refers to the obstruction of the refers to the obstruction of the pulmonary artery or one of its pulmonary artery or one of its branches by a thrombus (or branches by a thrombus (or thrombi) that originates thrombi) that originates somewhere in the venous somewhere in the venous system or in the right side of the system or in the right side of the heart heart

Causes Causes 1.thrombous 1.thrombous 2. embolism 2. embolism 3.trauma 3.trauma 4. surgery 4. surgery 5. hypercoaguability5. hypercoaguability 6. heart failure 6. heart failure 7. pregnancy ( increase coaguability 7. pregnancy ( increase coaguability

of BLof BL 8. older than 50 years 8. older than 50 years 9. atrial fibrillation 9. atrial fibrillation

Pathophysiology Pathophysiology

-When a -When a thrombus completely or thrombus completely or partially obstructs a pulmonary partially obstructs a pulmonary arteryartery or its branches, or its branches,

the alveolar dead space is increasedthe alveolar dead space is increased. . The area, although continuing to be The area, although continuing to be ventilated, receives ventilated, receives little or no blood little or no blood flowflow. Thus, . Thus, gas exchange is impairedgas exchange is impaired or absentor absent in this area. in this area.

PathophysiologyPathophysiology

-In addition, various -In addition, various substances are substances are released from the clotreleased from the clot and and surrounding area, surrounding area, causing regional causing regional blood vessels and bronchioles to blood vessels and bronchioles to constrict.constrict.

This causes an This causes an increase in increase in pulmonary vascular resistance.pulmonary vascular resistance. This This reaction compounds (reaction compounds (the ventilation–the ventilation–perfusion imbalance.)perfusion imbalance.)

PathophysiologyPathophysiology -The hemodynamic consequences -The hemodynamic consequences

are are increased pulmonary vascular increased pulmonary vascular resistanceresistance from the regional from the regional vasoconstriction and reduced size of vasoconstriction and reduced size of the pulmonary vascular bed. the pulmonary vascular bed.

This results in an This results in an increase in increase in pulmonary arterial pressurepulmonary arterial pressure and, in and, in turn, an turn, an increase in right ventricular increase in right ventricular workwork to maintain pulmonary blood to maintain pulmonary blood flow. Whenflow. When

PathophysiologyPathophysiology

the work requirements of the the work requirements of the right ventricle exceed its right ventricle exceed its capacity,capacity,

right ventricular failureright ventricular failure occurs, occurs, leading to a leading to a decrease in cardiac decrease in cardiac outputoutput followed by a followed by a decrease in decrease in systemic blood pressuresystemic blood pressure and the and the development of development of shock.shock.

RISK FACTORSRISK FACTORS Venous Stasis (slowing of blood flow in Venous Stasis (slowing of blood flow in

veins)veins) -Prolonged immobilization (especially -Prolonged immobilization (especially

postoperative)postoperative) -Prolonged periods of sitting/traveling-Prolonged periods of sitting/traveling -Varicose veins-Varicose veins -Spinal cord injury-Spinal cord injury -Hypercoagulability (due to release of tissue -Hypercoagulability (due to release of tissue

thromboplastin after injury/surgery) thromboplastin after injury/surgery) --InjuryInjury -Tumor (pancreatic, GI,, breast, lung)-Tumor (pancreatic, GI,, breast, lung) -Increased platelet count (polysalathemia, -Increased platelet count (polysalathemia,

splenectomy splenectomy

RISK FACTORS RISK FACTORS --Venous Endothelial DiseaseVenous Endothelial Disease -Thrombophlebitis -Vascular disease-Thrombophlebitis -Vascular disease -Foreign bodies (IV/central venous -Foreign bodies (IV/central venous

catheters)catheters) -Certain Disease States -Certain Disease States

(combination of stasis, coagulation (combination of stasis, coagulation alterations, and venous injury)alterations, and venous injury)

-Heart disease (especially heart failure)-Heart disease (especially heart failure) -Trauma (especially fracture of hip, -Trauma (especially fracture of hip,

pelvis, vertebra, lower extremities)pelvis, vertebra, lower extremities)

RISK FACTORSRISK FACTORS

-Postoperative state/postpartum period-Postoperative state/postpartum period -Diabetes mellitus -Diabetes mellitus -Chronic obstructive pulmonary disease c -Chronic obstructive pulmonary disease c

o p Do p D --Other Predisposing ConditionsOther Predisposing Conditions -Advanced age -Obesity -Pregnancy-Advanced age -Obesity -Pregnancy -Oral contraceptive use -Constrictive -Oral contraceptive use -Constrictive

clothingclothing --History of previousHistory of previous thrombophlebitis, thrombophlebitis,

pulmonary embolismpulmonary embolism

Clinical ManifestationsClinical Manifestations 1.1.DyspneaDyspnea is the most frequent is the most frequent

symptom; symptom; tachyapneatachyapnea (very rapid (very rapid respiratory rate) is the most frequent respiratory rate) is the most frequent sign . sign . The duration and intensity of the The duration and intensity of the dyspnea depend on the extent of dyspnea depend on the extent of embolization.embolization. Chest painChest pain is common and is common and is usually sudden and pleuritic. It may be is usually sudden and pleuritic. It may be substernal and misdiagnosed with substernal and misdiagnosed with angina pectoris or a myocardial angina pectoris or a myocardial infarction.infarction.

- - Other symptomsOther symptoms include anxiety, fever, include anxiety, fever, tachycardia, apprehension, cough, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope.diaphoresis, hemoptysis, and syncope.

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

--The diagnostic workup includes aThe diagnostic workup includes a - ventilation–perfusion scan,- ventilation–perfusion scan, -pulmonary angiography, -pulmonary angiography, -chest x-ray-chest x-ray -, ECG, -, ECG, -peripheral vascular studies, and -peripheral vascular studies, and

arterial blood gas analysis.arterial blood gas analysis. -Doppler ultrasonography and -Doppler ultrasonography and

venographyvenography

PreventionPrevention

prevent deep venous thrombosis. prevent deep venous thrombosis. 1. active leg exercises 1. active leg exercises 2. The intermittent pneumatic leg 2. The intermittent pneumatic leg

compression device ( reduces venous compression device ( reduces venous stasis). stasis).

3. use of elastic compression 3. use of elastic compression stockings stockings

4. anticoagulant therapy 4. anticoagulant therapy

Medical ManagementMedical Management

• • General measures to improve General measures to improve respiratory and vascular statusrespiratory and vascular status

• • Anticoagulation therapyAnticoagulation therapy • • Thrombolytic therapyThrombolytic therapy • • Surgical interventionSurgical intervention

GENERAL MANAGEMENTGENERAL MANAGEMENT

--Oxygen therapyOxygen therapy is administered to is administered to correct the hypoxemia, relieve the correct the hypoxemia, relieve the pulmonary vascular vasoconstriction, pulmonary vascular vasoconstriction, and reduce the pulmonary and reduce the pulmonary hypertension. hypertension.

--Using elastic compression stockingsUsing elastic compression stockings or intermittent pneumatic leg or intermittent pneumatic leg compression devices reduces venous compression devices reduces venous stasis. stasis.

GENERAL MANAGEMENTGENERAL MANAGEMENT

-These measures compress the -These measures compress the superficial veins and increase the superficial veins and increase the vesecosity of blood in the deep vesecosity of blood in the deep veins by veins by redirecting the blood redirecting the blood through the deep veinsthrough the deep veins..

Elevating the legElevating the leg (above the level (above the level of the heart) also increases of the heart) also increases venous flow.venous flow.

Anticoagulation TherapyAnticoagulation Therapy

.. Anticoagulant therapy (heparin, Anticoagulant therapy (heparin, warfarin sodium)warfarin sodium)

has traditionally been the has traditionally been the primary method for managing primary method for managing acute deep vein thrombosis and acute deep vein thrombosis and PE PE

Anticoagulation TherapyAnticoagulation Therapy

HeparinHeparin is used to is used to prevent prevent recurrence of emboli but has no recurrence of emboli but has no effect on emboli that are already effect on emboli that are already present.present.

It is administered as an It is administered as an intravenous intravenous bolusbolus of of 5,000 to 10,000 units5,000 to 10,000 units, , followed by a continuous infusion followed by a continuous infusion initiated at a dose of 18 U/kg per initiated at a dose of 18 U/kg per hour, not to exceed 1,600 U/hourhour, not to exceed 1,600 U/hour

Thrombolytic TherapyThrombolytic Therapy

-Thrombolytic therapy (urokinase, -Thrombolytic therapy (urokinase, strepto-kinase, alteplase, strepto-kinase, alteplase, anistreplase, reteplase) also may be anistreplase, reteplase) also may be used in treatingused in treating

PE, particularly in patients who are PE, particularly in patients who are severely compromised (eg, those who severely compromised (eg, those who are are hypotensivehypotensive and have significant and have significant hypoxemiahypoxemia despite oxygen despite oxygen supplementation). supplementation).

--

Thrombolytic TherapyThrombolytic Therapy

Thrombolytic therapyThrombolytic therapy resolves the thrombi or emboli more resolves the thrombi or emboli more

quicklyquickly restores more normal hemodynamic restores more normal hemodynamic

functioning of the pulmonary functioning of the pulmonary circulation, circulation, Reducing pulmonary Reducing pulmonary hypertensionhypertension

Improving perfusion, oxygenation, and Improving perfusion, oxygenation, and cardiac output.cardiac output.

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

--Pulmonary embolectomyPulmonary embolectomy requires a requires a thoracotomy with cardiopulmonary by- thoracotomy with cardiopulmonary by- pass technique.pass technique.

--Transvenous catheter embolectomy is a technique in which a vacuum-is a technique in which a vacuum-cupped cupped catheter is introduced catheter is introduced transvenously into the affected transvenously into the affected pulmonary artery. Suction is applied to pulmonary artery. Suction is applied to the end of the embolus and the the end of the embolus and the embolus is aspirated into the cupembolus is aspirated into the cup. .

Nursing ManagementNursing Management

MINIMIZING THE RISK OF MINIMIZING THE RISK OF PULMONARY EMBOLISMPULMONARY EMBOLISM

PREVENTING THROMBUS PREVENTING THROMBUS FORMATIONFORMATION

ASSESSING POTENTIAL FOR ASSESSING POTENTIAL FOR PULMONARY EMBOLISMPULMONARY EMBOLISM

MONITORING THROMBOLYTIC MONITORING THROMBOLYTIC THERAPYTHERAPY

MANAGING PAINMANAGING PAIN

Nursing management Nursing management

MANAGING OXYGEN THERAPYMANAGING OXYGEN THERAPY RELIEVING ANXIETYRELIEVING ANXIETY MONITORING FOR MONITORING FOR

COMPLICATIONSCOMPLICATIONS PROVIDING POSTOPERATIVE PROVIDING POSTOPERATIVE

NURSING CARENURSING CARE PROMOTING HOME AND PROMOTING HOME AND

COMMUNITY-BASED CARECOMMUNITY-BASED CARE

Mention nursing process of patient Mention nursing process of patient have Pulmonary Embolism ? have Pulmonary Embolism ?

DEFINE the following?DEFINE the following? thrombus thrombus Embolism Embolism Pulmonary vascular resistancePulmonary vascular resistance -Pulmonary arterial pressure-Pulmonary arterial pressure-The intermittent pneumatic leg -The intermittent pneumatic leg

compression device compression device -Cardiopulmonary by pass technique-Cardiopulmonary by pass technique

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