Test 5 Ch. 21 Pulmonary Vascular Disease Flashcards
A blood clot that forms and remains in the vein is called a
thombus
A blood clot that becomes dislodged and travels to another part of the body is called an
embolus (embolism)
A blood clot that went to the lungs
Pulmonary Embolism (PE)
When the embolus significantly disrupts pulmonary arterial blood flow…..
Which in turn can cause
pulmonary infarction; atelectasis, consolidation, and tissue necrosis
When a large embolus detaches from a thrombus and passes through the right side of the heart, where it may lodge in the bifurcation of the pulmonary artery is referred to as
saddle embolus
A large saddle embolus is often quickly _________, b/c it can significantly block ______________ _________ from returning to the left __________ and being pumped out the ___________ ______________
fatal
pulmonary blood
ventricle
systemic circulation
Pathologic or structural changes associated with PE
- Pulmonary hypertension
- Right- heart failure (cor pulmonale)
- Pulmonary infarction (when severe)
- Alveolar atelectasis
- Alveolar consolidation
- Bronchial smooth muscle constriction (Bronchospasm)
Risk Factors associated with PE: Venous Stasis (not moving) 6
- Inactivity
- Prolonged bed rest/ immobilization
- Prolong sitting (car or plane travel)
- CHF
- Varicose veins
- Thrombophlebitis
Risk Factors associated with PE: Surgical Procedures (4)
- Hip surgery
- Pelvic surgery
- Knee surgery
- Certain obstetric or gynecologic procedures
Risk Factors associated with PE: Trauma (5)
- Bone fractures
- Extensive injury to soft tissue
- Post op or postpartum states
- Extensive him or abdominal operations
- “milk-leg” of pregnancy
Risk Factors associated with PE: Hypercoagulation Disorders (3)
- Oral contraceptives
- polycythemia
- multiple myeloma
Risk Factors associated with PE:others
- Obesity
- Pacemakers or venous catheters
- Pregnancy or childbirth
- Supplement estrogen
- Family history of clots
- Smoking
- Malignant neoplasm
- Burns
Clot that forms in the veins of the lower extremities
Deep vein thrombosis (DVT)
Sudden death is often the first symptom in about % of ppl who have a large PE
25%
In the U.S about _____ individuals die each year from a PE
100,000
There are three primary factors (known as the Virchow triad) associated with the formation if DVT:
- venous stasis
- hypercoagulability (increased tendency of blood to form clot)
- injury to the endothelial cells that line the vessels
The diagnosis tests of a PE are (3)
- blood tests
- venous ultrasonography
- one or more lung imaging techniques
Common tests done for suspected PE
- Blood test
- D-Dimer Blood test
- Ultrasonography
- Chest x-ray
- Computed Tomography Pulmonary Angiogram (CTPA)
- Ventilation-Perfusion Scan
- Pulmonary Angiogram
- Magnetic Resonance Imagining
- Magnetic Resonance Angiography
This test is used to check for an increased level of protein fibrinogen, an integral component of the blood-clotting process
D- dimer blood test
D-dimer blood test is also called the
fibrinogen test
The d-dimer test is relatively _______ and _____; it entails drawing a blood sample and the results can be available in less than
simple and fast; 1 hour
D-dimer values higher than _____ ng/mL are considered ____________, which may suggest the _____________ of blood clots
500
positive
possibility
A normal d- dimer level essentially rules out the
possibility of blood clots
This test uses high- frequency sound waves to detect blood clots in the thigh veins
ultrasonography
The ultrasonography test is ______________ and takes only _____ minutes or less to perform
noninvasive
30
Ultrasonography is very accurate for the diagnosis of blood clots behind
the knee or thigh
This test can be used to rule out conditions that mimic a PE, such as PNA and pneumothorax
Chest Xray
___________ and __________ will be seen in _____% of PE and an elevated _______________ occurs in as many as ___% of cases (when using a chest X-ray)
infiltrates and atelectasis; 50%
hemidiaphragm; 40%
The spiral (helical) volumetric……….. w/ intravenous contrast is fast becoming the first-line test for diagnosis suspected PE
computed tomography pulmonary angiogram (CTPA)
computed tomography pulmonary angiogram (CTPA) is also called
CT pulmonary angiography
The CTPA is increasingly being preferred as the gold standard for diagnosing PE over V/Q scanning or direct pulmonary angiogram b/c (4)
- the scan requires only an iv line
- the imaging resolution is very good
- the volumetric scanning allows the contrast material to be administered more economically and timed more precisely
- the entire chest can be scanned in a single breath hold or in several successive short breath holds
This scan is rarely used to identify a PE
V/Q scan
This test provides a clear image of the blood flow in the lung’s arteries
pulmonary angiogram
This test may be used on individual’s whose kidneys may be harmed by dyes used in x-ray tests and for women who are pregnant
MRI
This test may be used to differentiate among blood (usual) thromboemboli, and tumor emboli in pts w/ malignacy
MRA
Signs and symptoms Commonly Associated w/ PE
sudden SOB
cardiac arrhythmias
- sinus tachycardia
- atrial arrhythmias
- atrial tachycardia
- atrial flutter
weak pulse
lightheadednesss or fainting
anxiety
excessive sweating
cyanosis
Chest pain. that resembles a heart attack
cough
blood-streaked sputum
wheezing
leg swelling
Clinical manifestation of PE (2)
- atelectasis
- bronchospasm
Vital signs for PE
- Increased RR
- Increased HR
- Decreased BP
When blood flow is reduced or completely absent distal to the obstruction, the alveolar ventilation and no carbon- dioxide- oxygen exchange. The V/Q ratio distal to the PE is high and may even be infinite if there is no perfusion
Increased Physiologic (Alveolar) Dead Space
What is the normal pulmonary hydrostatic pressure
15 mm Hg
What is the normal oncotic pressure
25 mm Hg
When the pulmonary hydrostatic becomes higher than the Pulmonary oncotic pressure, what does this result in?
pulmonary hypertension
The increase in the hydrostatic pressure permits plasma and RBC to move across the alveolar-capillary membrane and into alveolar spaces in a process similar seen in
cariogenic pulmonary edema
If the process continues will result in
stimulation and a cough reflex and the expectoration of blood-tinged Sputum
Peripheral Edema and Venous Distention (4)
- Distended neck veins
- Swollen and tender liver
- Ankle and feet swelling
- Pitting edema
This is frequently noted in pts w/ PE. The origin of the pain is unknown. It may be cardiac or pleuritic, but it is one of the common early findings in all forms of PE (2)
- Chest pain
- Decreased Chest Expansion
Chest assessment findings (3)
- crackles
- wheezes
- Pleural friction rub (especially when pulmonary infarction involves the pleura)
Abnormal EKGs (2)
- Sinus tachycardia
- Atrial arrhythmia
Chest Xray
- Increased density
- Hyperradiolucency
- Dilation of the pulmonary Arties
- Right ventricular cardiomegaly (cor pulmonale)
- Pleural effusions (usually small)
An increased in mean pulmonary artery pressure greater than 25 mm Hg at rest is called
Pulmonary hypertension (PH)
Normal range for mean pulmonary artery pressure
10 to 20 mm Hg
PH is a frequent complication of a
chronic pulmonary disease
PH is more common in
With a ratio of
women than men
3:1
W.H.O divided PH into
five different group classifications based on the cause and tx options
PH can be very ________, the pt may have mild to moderate PH for years w/ no remarkable signs and symptoms
insidious
The diagnosis of PH is based on the pt’s (3)
- medical and fam history
- physical examination
- and the results from variety of test and procedures
What test may be used to diagnose PH? (4)
- echocardiography
- chest x-ray
- electrocardiograms
- right- heart catherization
Which sided heart failure is more commonly the cause of PH?
left-sided heart failure (CHF)
left-sided and right-sided heart failure combined is called
biventricular failure
What is the role fast acting anticoagulants?
To prevent existing blood clots from growing and prevent the formation of new ones
This has been used until recently to tx pts with acute PE, and bleeding can occur with this
High- molecular-weight heparin (unfractionated heparin)
This has become widely available and have been shown to be safer and more effective than unfractionated heparin. More cost effective
low-molecular-weight heparins
Example of a High- molecular-weight heparin
Heparin
Example meds of low-molecular-weight heparins ( EDT)
- enoxaparin
- dalteparin
- tinzaparin
Heparin can be given thru an
IV
slow-acting, oral anticoagulant
warfarin
Warfarin is also called (2)
- Coumadin
- Panwarfarin
Warfarin can be given
orally
These actually dissolve the clots
thrombolytic agents
What are some thrombolytic agents (4)
- streptokinase (Streptase)
- urokinase (Abbokinase)
- altreplase (Activase)
- reteplase (Retavase)
thrombolytic agents are commonly referred to as
“clot- blusters”
Thrombolytics agents are sometimes used in
conjunction w/ heparin
Preventive measures fo PE: (4)
- Walking
- Exercise while seated
- Drink fluids
- Wear graduated compression stockings
This may be surgically placed in the inferior vena cava to prevent clots being carried into the pulmonary circulation
inferior vena cava (Greenfield) vein filter
IVC is recommended only in
high risk pts
This tx uses thigh high cuffs that automatically inflate every few minutes to massage and compress the veins in the pt’s legs
Pnuematic Compression (SCD)
Surgically removal of blood clots is generally the last resort in treating PE b/c f the mortality rate
Pulmonary embolectomy
Protools (3)
- Oxygen therapy
- Aerosolized Medication
- Lung Expansion
PH has no
cure, tx may help reduce symptoms
Therapies commonly used to treat all types of PH:
- Diuretics
- Phosphodiesterase inhibitors
- Blood- thinning medications
- Cardiac glycosides (digoxin)
- o2 therapy
- Inhaled nitric oxide (iNO)
Common signs and symptoms of PH: General Findings
- Dyspnea
- Lightheaded, dizziness, confusion
- Fatigue
- Nonproductive cough
- Hemoptysis
- Chest pain/ decreased chest excursion
- Cyanosis
Common signs and symptoms of PH: Test and Procedure Findings
- Abnormal heart sounds
- Palpable right ventricle heave or lift
- sinus tachycardia
- atrial arrhythmia
Signs and symptoms of Right sided heart failure (cor pulmonale)
- SOB
- Irregular fast heart rate
- Distended neck vein
- Swollen and tender liver
- Ankle and feet swelling
- Pitting edema
- Heart palpitations
- Nausea
- Weight gain
Signs and symptoms of Left-sided heart failure (CHF)
- SOB
- Frothy, blood-tinged sputum
- Crackles
- Cough and hemoptysis
- Weak pulse
- Decreased urine production
- Cyanosis
- Excessive sweating
Questions from the back
Most pulmonary emboli originate from thrombi in the
Leg and pelvic veins
The aortic and carotid sinus baroreceptors initiate which of the following in response to a decreased systemic BP (2) (vitals)
Increased HR
Increased ventilatory rate
What is the upper limit of the normal mean pulmonary artery pressure?
15 mm Hg
PH develops in PE b/c of
- Vasconstriction caused by humoral agent release
- Vasoconstriction induced by decrease PaO2`
In severe PE what hemodynamic indices is commonly seen?
- Increased mean pulmonary artery pressure
Which of the following are thrombolytic agents
- Urokinase
- Streptokinase
Which of the following is most prominent source of PE
blood clots
PH is defined as an increase in mean pulmonary pressure greater than
25 mm Hg
What are the cardiac arrhythmias for PE (4)
- sinus tachycardia
- atrial arrhythmias
- atrial tachycardia
- atrial flutter
