Unit 1: Pulmonary Embolism (PE)

Question 1

What are the three types of emboli?

Answer 1

1. Air
2. Liquid
3. Solid (blood clot)

Question 2

What happens when a large emboli obstructs pulmonary blood flow?

Answer 2

Reduced gas exchange → reduced oxygenation → pulmonary tissue hypoxia → decreased perfusion → DEEEEEEEEAAAAAAATH

Question 4

3 parts of Virchow’s triad

Answer 4

1. Hypercoagulability
2. Vascular damage
3. Circulatory stasis

Question 5

REVIEW: Name some things that could cause Hypercoaguability

Answer 5

1. Dehydration
2. Infection/sepsis
3. Inherited thrombophilia

Question 6

REVIEW: Name some things that could cause vascular damage

Answer 6

1. Thrombophlebitis/cellulitis
2. Venipuncture/IVs/CVADs
3. Indwelling cath/heart valve

Question 7

REVIEW: Name some things that could cause circulatory stasis

Answer 7

1. Immobility
2. venous obstruction (obesity, tumor, pregnancy)
3. Varicose veins
4. Afib/left ventricular dysfunction/bradycardia

Question 8

Most common cause of a PE and the #1 prevention priority is…

Answer 8

DVT! Want to prevent these buggers

Question 9

Name some DVT Prevention, especially after surgery (8)

Answer 9

1. Ambulation ASAP
   
   • ROM exercises + position changes q 2 hrs if immobile
2. Pneumatic compression devices as prescribed
3. Anticoagulant therapy after bleeding risk is subsided
   
   • low-dose anticoags or anti-plts
4. Peripheral circulation assessment q 8
5. Alternating pressure mattress (NOT pillows) to reduce pressure under popliteal space.
6. Elevate affected limb 20 degrees or more above level of heart to improve venous return
7. Avoid crossing legs, tight garters, girdles, & constricting clothes (lol we’re in the 19th century I guess…)
8. Refrain from massaging leg muscles
9. Inferior vena cava filter (IVC) placed preop for pts who’ll be stuck in bed for long time & have ongoing risk; removed when fully ambulatory

(pg. 587)

Question 10

The Respiratory S/S of a PE are r/t…
The Cardiac S/S of a PE are r/t…

Answer 10

Decreased gas exchange!
Decreased tissue perfusion!

Resulting Sxs vary depending on size + type of emboli

Question 11

What’s the most commonly occurring Symptom r/t a PE?

Answer 11

Sudden onset of dyspnea (SOB)

Question 12

Describe the chest pain r/t with a PE:

Answer 12

Sharp, stabbing chest pain on inspiration

Question 13

How might someone feel (mental status) if they have a PE?

Answer 13

Feeling of IMPENDING DOOOOOM!
Restless, Agitated, Apprehensive

Caused by poor oxygenation!

Question 14

What assessment finding might you find on the skin r/t a PE? (2)
What kind of fever might a pt present with?

Answer 14

1. Diaphoresis
2. Petechiae over chest and axillae

Low-grade fever

Question 15

Name some Respiratory S/S of a PE (4)

Answer 15

1. Cough
2. Hemoptysis (bloody sputum)
3. Tachypnea
4. Abnormal breath sounds (crackles, pleural rub)

Question 16

Name some Cardiac S/S of a PE (7)

Answer 16

1. Tachycardia
2. Distended neck veins
3. Syncope
4. Cyanosis (increased O2 demand)
5. Hypotension
6. Abnormal Hrt sounds (S3 or S4)
7. ECG changes (nonspecific + transient T-wave + ST-segment changes, &/or left-axis or right-axis deviations)

Question 17

Why might hypotension occur with a PE? Is this a big deal?

Answer 17

Right-sided HF due to pulmonary congestion AND inflammatory response

NOT OKAY!
Can result in SUDDEN DEATH due to cardiac arrest or frank shock!

Question 18

What is the PaO2/FiO2 ratio?

Answer 18

The ratio of arterial O2 partial pressure (PaO2 in mmHg) to the fraction of inspired O2 (FiO2 as a fraction, not %)

Used to determine the severity of lung injury

Question 19

Diagnostic testing for a PE (5 labs, 5 imaging)
What’s the Gold standard for diagnosis?

Answer 19

Labs:
1. ABG
2. Basic Metabolic Panel (BMP–she said basic, but they’d do a comprehensive…)
3. TrpI
4. BNP
5. DDIM

Imaging:
1. Pulmonary Angiography*** GOLD STANDARD
2. CT-PA
3. CXR
4. Ultrasound (R/O underlying DVT in extremities)
5. Ventilation-Perfusion scan (V/Q)

Question 20

What would the ABG results look like initially and then as the PE progresses? Explain why this happens.

Answer 20

1st: Respiratory alkalosis
- Hyperventilation/low PaCO2)
2nd: Respiratory acidosis
- Shunting of deoxygenated blood;
- Decreased PaO2/FiO2 ratio, PaCO2 increases
3rd: Metabolic acidosis
- lactic acid buildup due to tissue hypoxia

Question 21

So what do we do if we suspect our pt has developed a PE? (3)

Answer 21

1. Raise HOB
2. Oxygen
3. GET HAAAAALP! (Call Rapid Response)

Question 22

What’s the priority planning for a pt with a PE? (3)

Answer 22

1. ABGs
2. Maintain SpO2 >95%
3. Maintain cognitive status baseline

Question 23

Interventions for a PE (7)

Answer 23

1. Raise HOB
2. Oxygen
3. GET HAAAAALP! (Call Rapid Response)
4. Reassure pt
5. Assess (Respiratory, Cardiac, skin)
6. Imaging
7. Admin prescribed Anticoagulants

Question 24

What assessments/precautions should we be performing if we’re administering anticoagulants?

Answer 24

Bleeding precautions/assessment!
Monitor CBC, aPTT, PT, INR, platelets
Antidotes for anticoags

Question 25

If the pt with a PE becomes hypotensive, what medications can we administer along with IV fluids?

Answer 25

1. Positive Ionotropic agents (milrinone, dobutamine)
2. Vasopressors (levophed, epi, norepi)
3. Vasodilators (nitroprusside)