DEFINITION
Pulmonary embolism is the blockage of pulmonary arteries by thrombus, fat or air emboli and tumour tissue.
It is the most common complication in hospitalized patients.
An embolus is a clot or plug that is carried by the bloodstream from its point of origin to a smaller blood vessel, where it obstructs circulation.
ETIOLOGY AND RISK FACTORS
Virtually all pulmonary embolisms develop from thrombi (clots), most of which originates in the deep calf, femoral, popliteal, or iliac veins.
Other sources of emboli include tumours, fat, air, bone marrow, amniotic fluid, septic thrombi, and vegetations on heart valves that develop with endocarditis.
Major operations, especially hip, knee, abdominal and extensive pelvic procedures predispose the client to thrombus formation because of reduced flow of blood through pelvis.
Traveling in cramped quarters for a long time or sitting for long periods is also associated with stasis and clotting of blood.
CLINICAL FEATURES
Severity of clinical manifestations of pulmonary embolism depends on the size of the emboli and the size and number of blood vessels occluded. Most common manifestations are
Anxiety
Sudden onset of unexplained dyspnea
Tachypnea or Tachycardia
Cough
Pleuritic chest pain
Hemoptysis
Crackles
DIAGNOSTIC TESTS
IMAGING STUDIES
CXR
V/Q Scans
Spiral Chest CT
Pulmonary Angiography
Echocardiography
LABORATORY ANALYSIS
CBC, ESR
D-Dimer
ABG’S
ANCILLARY TESTING
ECG
Pulse Oximetry
COMPLICATIONS OF PULMONARY EMBOLISM
Sudden cardiac death
Obstructive shock
Pulseless electrical activity
Atrial or ventricular arrhythmias
Secondary pulmonary arterial hypertension
Cor pulmonale
Severe hypoxemia
Right-to-left intracardiac shunt
Lung infarction
Pleural effusion
Paradoxical embolism
Heparin-induced thrombocytopenia
Thrombophlebitis
MEDICAL MANAGEMENT – PULMONARY EMBOLISM
Emergency Management
Nasal oxygen
IV infusion for medication
Perfusion scan
ABGs and ECG
Small dose of Morphine
Intubation and mechanical ventilation
MEDICATIONS
Anticoagulants are prescribed when pulmonary embolism is diagnosed or suspected
Heparin
Warfarin
Rivaroxaban
Fondaparinux
Most commonly the patient will take an anticoagulant for at least 3 months after pulmonary embolism to reduce the risk of having another blood clot.
SURGERY
Surgical management of acute pulmonary embolism (pulmonary thrombectomy) is uncommon and has largely been abandoned because of poor long term outcomes. However, recently, it came back again with the revision of the surgical technique and is thought to benefit certain people.
Chronic pulmonary embolism leading to pulmonary hypertension (known as chronic thromboembolic hypertension) is treated with a surgical procedure known as a pulmonary thromboendarterectomy.
NURSING MANAGEMENT OF PULMONARY EMBOLISM
Evaluation of risk factors on admission and during hospital stay
Encourage maximal mobility, range of motion and ambulation when appropriate or leg compression devices if on bed rest.
Administer anticoagulant medication – heparin continuous IV drip until Coumadin started and PT/INR is therapeutic
Monitor liver function when patients receive anticoagulants
Monitor Lab for anticoagulants effectiveness (Heparin-PTT q 6 hours till in range then q day)
Assess for symptoms of bleeding and heparin-induced thrombocytopenia (HIT)
IVC Filter – vena cava filter
