Pulmonary Embolism (PE)
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- Pulmonary Embolism (PE)
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-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 - Etiology
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-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. - Clinical Manifestations
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-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 - Complications
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-Death
-Pulmonary Infarction
-Pulmonary Hypertension - Pulmonary Infarction
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-Death of lung tissue
-Leads to alveolar necrosis and hemorrhage
-Dead tissue can become infected and abscess (pleural effusion) - Pulmonary Hypertension
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-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) - Diagnostic Studies
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-VQ Scan: Perfusion and Ventilation
-D-Dimer
-Pulmonary Angiography if VQ scan is inconclusive
-Spiral CT - VQ Scan
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-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 - D-Dimer
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-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) - Pulmonary Angiogram
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-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) - Spiral CT
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-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 - ABG - Arterial Blood Gases
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-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 - Objectives of treatment
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-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 - Treatment -- Medical
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-#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 - Anticoagulation
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-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 - IV Heparin
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1. Set up concentration in mL/units
2. Set up mL/hr
3. Determine mL/hr -
Deliver 1000 units per hour of IV heparin
Available is 25,000 units in 500 mL of D5W
Calculate mL/hr - mL=500mL/25,000 units X 1000 units/hr = 500,000/25,000 = 20 mL/hr
- Thrombolytic Therapy
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-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) - Circulatory Support
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-Vasopressor agents may be necessary to support systemic circulation (increase BP)
-Digitalis and diuretics are used if heart failure is present - Treatment -- Surgical
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-Embolectomy
-Intracaval filter devices (IVC's) to prevent further pulmonary embolism - Pulmonary Embolectomy
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-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) - Health Promotion
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-Risk factors parallel those for DVT (Table 37-7 Lewis)
-Prevention measures are the same as for the prophylaxis of DVT - Analysis/Diagnosis
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Actual:
-Impaired gas exchange
-Ineffective breathing pattern
-Anxiety - Analysis/Diagnosis (cont)
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Risk for ineffective therapeutic regime management
Potential Complications:
-PC:Hypoxemia
-PC:Impaired Tissue Perfusion
-PC:Decreased Cardiac Output
-PC:Bleeding - Acute Implementation
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-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 - Home Care
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-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 - Evaluations/Expected Outcomes
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-Adequate tissue perfusion and respiratory function
-Adequate cardiac output
-Increased level of comfort
-Absence of recurring PE/DVT
-Absence of bleeding - Current Trends
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-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 - Pleural Effusion
- Fluid in the thoracic cavity between the visceral and parietal pleura. It may be seen on a chest radiograph if it exceeds 300 mL
- cor pulmonale
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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)