Pulmonary embolism Flashcards
Overview of PE
- Obstruction of the pulmonary artery or one of its branches by a thrombus that originate in the venous system or right side of the heart
Other things that can cause a PE other than a blood clot
- Air Embolism
- Fat
- Amniotic fluid
- Septic emboli (from an infection)
Incidence of VTE
Probably dont need to know
- 1-2 per 1000 population per year
- Chronically underdiagnosed
- 10-20% med surg patients
- 30% of people with VTE will develop post thrombotic complications (Stroke/PE)
- Complications occur post discharge due to short hospital stays
Why are VTE underdiagnosed
- Silent and asymptomatic, often diagnosis of exclusion with subtle s+s
VTE patho
- Thrombus obstructs PA or its branches
- With it obstructed, alveolar become dead space with little to no blood flow
- Impaired or no gas exchange
- bronchoconstriction
- Increase in pulmonary vascular resistance
- V/Q mismatch
- Decreased CO
- Decreased BP
- Shock/Death
V/Q
- V= Ventilation
- Q= Quality of perfusion
Virchow triad
- Endothelial damage
- Venous stasis
- Altered coagulation
Processes that lead to clot formation
Virchow’s triad: Endothelial dmg
- Central venous cath
- Dialysis access
- Local vein dmg
- Pacing wires
- Surgery
- Trauma
(Introduction of something foreign to the vein)
Virchow’s triad: Venous stasis
- Age 65+
- Bed rest or immobilization
- HF
- Varicose veins
- Obesity
- Spinal cord injury
Virchow’s triad: Altered coagulation
- Chemo in cancer
- Polycythemia (Blood too thicc)
- Pregnancy
- Protein deficiency
- Septicemia
- Oral contraceptives
- Smoking
What protein deficiencies cause altered coagulation
Protein C and S
S+S PE
Often there is few S+S, or it can mimic a cardiopulmonary disorder (PNA, HF)
* Dyspnea
* CP, pleuritic pain
* Substernal angina
* Hypoxia with decreased PaCO2
* Anxiety and apprehension
* Fever (Low from inflammation)
* Tachycardia
* Cough hemoptysis
* Diaphoresis
* Tachypnea
* Syncope (No O2 to brain)
Pleuritic pain
Worse upon inspiration
Normal PaCO2
35-45 mmHg
Normal PaO2
80-100 mmHg
S+S PE: Obstruction of Pulmonary artery
- Dyspnea
- Sudden substernal pain
- Rapid and weak pulse
- Shock
- Syncope
- Sudden death
What should be done first for a pt with risk for a PE complains of CP and SOB
- Take the patient’s vital signs
- Position the patient for optimal ventilation
- Call the physician
- Connect the patient to a cardiac monitor
- Apply oxygen
- Position the patient for optimal ventilation
How soon can death occur with PE
Within 1 Hour of symptom onset
Main concern with Heparin
Bleeding
What are used to rule out other causes of S+S of PE
- CXR, ECG, ABG
What is primary test to diagnose PE
CT is number one
* Pulmonary angiography, provides direct visualization with contrast (More invasive like cardiac cath)
Both these use nephrotoxic contrast/ allergy
V/Q scan or V/Q SPECT
- Vent and perfusion, single emission computed tomography
- Nuclear medicine
- Uses radioisotopes IV and inhaled
- Used in renal failure or contrast allergy
- Caution in preg due to risk of radiation, needs smaller does
D dimer
Non specific test that says there is a clot, just not where
Test done for Heparin
Ptt/Pt
drawn every 6 hours till therapeutic
Anti Xa done for low molecular weight heparin
Test done for warfarin/ coumadin
PT/INR
Antidote for coumadin
Vitamin K
Anticoagulation therapy
- IV heparin during the acute period
- Low-molecular weight heparin used after
- Warfarin (Coumadin) used at home (3-6 mo)
LMWH examples
- fondaparinux (arixtra)
- enoxaparin sodium (lovenox)
- Unfractionated heparin in renal impairment
Collaborative care of PE mgmt
- O2 admin
- IV access
- Treat hypotension (Vasopressors)
- Pulse Ox, ABG, VS
- ECG
- Labs (Electrolytes,CBC, colagulation)
- Foley cath
- Fibrinolytics (TPA) or heparin
- IV morphine or sedatives
- Limited activity in the acute phase (BR, semi-fowlers), especially if anticoagulated can cause a stroke
- Gradual early ambulation post acute phase
Thrombolytic (Fibrinolytic) Therapy
- TPA
- Used to treat massive PE that affects significant area of blood flow to the lungs and causes hemodynamic instability
- Tissue plasminogen activator, (TPA), dissolves the clot
- Bleeding is a huge side effect
Contraindications for TPA
- CVA in the past 2 mo
- Active bleeding
- Surgery within 10 days
- Recent labor and delivery
- Trauma
- Severe hypertension (Not actually they just treat the hypertension)
Alternative treatment for PE involves use of subcutaneous low molecular weight heparin (LMWH) (enoxaparin). In patients receiving low molecular weight heparin, which of the following lab values is monitored?
1. Prothrombin time (PT)
2. Platelet count
3. Activated partial thromboplastin time (APTT)
4. International normalized ratio (INR)
- Platelet count, LMWH plt count is a huge concern
IVC filter
- Vena cava filter that is used in some pt who are at risk for future emboli
- Vena cava filter is placed percutaneously in the inferior vena cava, acting to block clots traveling up from distal extremities before they reach the lungs
- Used in old people who shouldn’t be on anticoagulants
Surgical mgmt of PE
Suction embolectomy, surgical removal of emboli
Nursing mgmt of VTE
- Identify High risk pts (Everyone is high risk in the hospital)
- Preventive measures
- Active and passive ROM to avoid venous stasis
- Early ambulation
- No leg crossing
- Anti embolic stockings
- Remove unnecessary IV’s, central lines
Prevention of VTE
- Early ambulation
- SCD
- Prophylactic anticoagulants (Lovenox), heparin before surgery because of short half life
Nursing mgmt of acute VTE/PE
- Assess extremities for warmth redness, inflammation, pain
- Pain meds
- Semi-fowler’s position, T+P
- Monitor pulse ox for hypoxemia
- Continuous O2 when warranted
- Deep breathing and incentive spirometer
Patient teaching: Anticoagulants/ Lab work
- Side effects are bleeding and bruising
- Avoid razors
- Soft bristle toothbrush
- No ASA while on coumadin
- Report dark tarry stools
- Carry a card stating anticoagulant therapy
Patient teaching: Strategies to prevent DVT and PE
- Compression stockings
- Avoid periods of long sitting or standing (Travel)
- Push fluids
- Know S+S recurrence
