Pulmonary Embolism / Pulmonary Edema

Question 1

Excess fluid in the lungs (not the pleural space) =

Answer 1

pulmonary edema

Question 2

causes of pulmonary edema

Answer 2

• Happens a lot in older folks –> decreased heart/kidney function
◦ HF
◦ Renal failure
◦ ARDS
◦ High altitudes
◦ Brain trauma
◦ Rapidly expanding lungs
— pneunothorax –> Pulling fluid off lungs too quickly when re-expanding the lung
◦ Most common: When giving too much fluid too quickly

Question 3

what happens when fluid accumulates in the alveoli

Answer 3

cant exchange O2/Co2

Question 4

on a patho level what is causing pulmonary edema (not diseases)

Answer 4

• Increased pulmonary pressure increases, fluid leaks across pulmonary capillaries into airway and tissue

Question 5

which is bigger deal- acute pulmonary edema or pulmonary edema

Answer 5

Acute Pulmonary Edema (formerly known as flash pulmonary edema)
=Life threatening emergency

Question 6

who is highest risk of acute pulmonary edema

Answer 6

• HF, renal, older folks
• Laboring parents on a lot of fluid can happen
◦ Results from severe fluid overload

Question 7

acute pulmonary edema assessment findings

Answer 7

• Coarse Crackles (especially in bases)
• Cough
• SOB
• Pink, frothy sputum**
• Dyspnea
• Confusion
• Tachy/Dysrythmias
• Altered BP (low , high, or normal)
• Reduced urinary output (low cardiac output)
• Restlessness/anxiety
• Lethargy

Question 8

interventions for pulmonary edema

Answer 8

• Reassurance
• HOB raised
• O2 increase
• Monitor SpO2, Vital signs
- Meds
• FIX UNDERLYING CAUSES
• Ultrafiltration
• Use ABC’s
• O2
◦ Face mask
◦ Noninvasive positive pressure ventilation (Bipap cpap)
◦ Intubation/Mechanical ventilation

Question 9

meds we might give for pulmonary edema

Answer 9

nitroglycerin, morphine, diuretics, antihypertensives, dobutamine

Question 10

which drug reduces preload (pulmonary venous return) :

diuretic, antihypertensive, or dobutamine

Answer 10

diuretic

Question 11

which drug provide ionotropic support (heart contraction):

diuretic, antihypertensive, or dobutamine

Answer 11

dobutamine

Question 12

which drug reduces the afterload (systemic vascular resistance):

diuretic, antihypertensive, or dobutamine

Answer 12

antihypertensive

Question 13

goals for managing pulmonary edema long term? who do you want on the team for helping to manage them?

Answer 13

-manage underlying diseases that cause pulmonary edema
-HF core measures
◦ Discharge instructions
◦ Left ventricular systolic function
◦ ACE or ARB
◦ Smoking cessation
-• Activity as tolerated / Work up to routine exercise

-case management/social worker

Question 14

HF core measures re: managing pulmonary edema

Answer 14

◦ Discharge instructions
◦ Left ventricular systolic function
◦ ACE or ARB
◦ Smoking cessation

Question 15

A PE is caused by a blockage- what kind of things can block your vessels?

Answer 15

air, liquid, solid

Question 16

Take me through the patho of what happens when you have a PE

Answer 16

• Reduced gas exchange
• Reduced oxygenation
• Pulmonary tissue hypoxia
• Decreased perfusion –> increases resistance in pulmonary vasculature –> increase work of R side of heart to push blood out into the lungs –> R sided HF –> poor perfusion to rest of body
• Possible death

Question 17

Most common cause of a PE =

Answer 17

DVT! VTE (venous thromboembolism)

Question 18

Path of DVT to PE

Answer 18

DVT → dislodges → vena cava → right atrium → right ventricle → pulmonary vessels → platelets aggregate → triggers other substances that cause vessel constriction
→ Impaired gas –> impaired tissue perfusion –> hypoxemia

Question 19

When the DVT dislodge and goes into your pulmonary vasculature what happens to the right side of the heart?

Answer 19

becomes hard to the right ventricle to push blood into the lungs

Question 20

What puts someone at increase risk of DVT/PE

Answer 20

• Increased age
• Hypercoagulable states
• Obesity
• hypercoagulable state
• Prolonged immobility
• Central venous catheter
• IV drug use
• Sepsis

Question 21

virchow’s triad =

Answer 21

= increase risk of developing a blood clot from
1.) damage to vessel (trauma)
2.) immobility (stasis of blood flow)
3.) hypercoagulability

Question 22

The best way to manage a DVT is to ….

Answer 22

prevent it!!

use anticoagulant, mobility, SCD’s

Question 23

asssesment findings for PE

Answer 23

• Resp compromise
• Dyspnea
• Chest pain – stabbing, sharp
◦ heart attack = squeezing, crushing
• Restlessness
• Agitation
• Cough
• Bloody sputum from infarcted lung (Pulmonary Edema = pink frothy)
• Abnormal breath sounds
• Tachypnea
• Tachycardia
• Diaphoresis
• Fever- inflammation
• Petechiae (throwing blood clots, hemorrhaging of small capillaries)
• Showering clots
• Increased O2 demands
• Hypotension from decreased cardiac output
• Abnormal heart sounds
• EKG changes

Question 24

sputum with PE vs sputum with Pulmonary edema

Answer 24

PE = bloody from infarcted lung
Pulm Edema = pink frothy

Question 25

heart attack chest pain vs PE chest pain

Answer 25

heart attack = squeezing crushing
PE = stabbing, sharp

Question 26

diagnostics for PE (long list)

Answer 26

• ABG
• BMP
• Troponin
• BNP
• D-Dimer
◦ All it tells us is that there is a blood clot somewhere
• Pulmonary angiography = looks for blood clot in the lungs
• CT-PA
• Ventilation – perfusion scan (V/Q)
• There would be a mismatch
• Chest x-ray
• Ultrasound → Looking for an underlying DVT

Question 27

this lab value tells us there is clot somewhere but not specifically where

Answer 27

D- dimer

Question 28

gold standard for diagnosing a PE

Answer 28

pulmonary angiography

Question 29

What do you do if you suspect someone has a PE?

Answer 29

get some help!!

Question 30

3 priority responses for PE management

Answer 30

• ABG’s with normal limits
• Give O2 to maintain SpO2 > 95%
• Patient maintain baseline cognitive status

Question 31

Interventions for PE

Answer 31

• HOB
• Increase O2 to maintain SpO2 > 95%
• Call RR
• Reassure your patient
• Assess, assess, assess
◦ Respiratory
◦ Cardiac
◦ Skin
• Imaging
• Prescribed anticoagulants (monitor bleeding!!)

Question 32

Which anticoag med works the fastest?

Answer 32

Heparin

Question 33

what labs do we check with heparin ? what labs do we check with warfarin?

Answer 33

heparin = ptt or APTT
warfarin = INR

Question 34

how soon do we check aptt or ptt with heparin

Answer 34

within 6 hours check ptt or aptt

Question 35

if your patient is going for a prcedure and they are heparin how long do you have to wait after stopping the heparin for them to go have the procedure?

Answer 35

stops working within 1 hour of turning off the infusion

Question 36

antidote for heparin? antidote for warfarin?

Answer 36

heparin= protamine sulfate
warf = vitamin k

Question 37

how long after stopping lovenox can patient or procedure?

Answer 37

12 hours

Question 38

which are the 2 acute anticoags and who is our typical extended?

Answer 38

acute = heparin, lovenox
extended = warfarin

Question 39

other extended anticoags you might d/c someone with

Answer 39

◦ Rivaroxaban
◦ Dabigatran
◦ Apixaban

Question 40

How do we know the anticoagulant meds are working to treat the PE?

Answer 40

clot is getting smaller = breathing better

Question 41

surgical intervention for PE (2) - which one is a temporary solution and why would we do it?

Answer 41

• Embolectomy
• Inferior vena cava filtration
◦ Filter to catch clot if they cannot receive anticoagulants , temporary measuer

Question 42

what do we do to treat hypotension related to HF from a PE

Answer 42

-in fluids
-iv drug therapy
-positive inotropic meds
-vasopressors
-vasodilators

Question 43

managing and preventing bleeding measures

Answer 43

• Assess for bleeding
• Education your patient
• Antidotes
• Monitor CBC, aPTT, PT, INR, platelets
• Bleeding preventions

Question 44

if you have a patient on apixaban do they require lab monitoring?

Answer 44

nope!

Question 45

2 tools to manage PE anxiety

Answer 45

• Communication!!
◦ stay with the patient
• Pharmaceuticals
◦ morphine, ativan

Question 46

when d/cing a patint with PE what things do we need to consider?

Answer 46

Going Home
• Anticoagulation therapy
• Home oxygen?
• Home health
• Follow up care