Pulmonary embolism is a

common and often fatal

disease.
Mortality can be reduced
by prompt diagnosis and
therapy.
Clinical presentation of PE
is variable and
nonspecific ,making
accurate diagnosis
difficult.
2/3 of the patient
remained undiagnosed.

In a study of more than 42

million deaths that occurred over
a 20 year duration .
Almost 600,000 patients
(approximately 1.5 percent)had
been diagnosed with PE.
Estimates of the incidence of PE
have been affected by the
introduction of computed
tomographic pulmonary
angiography(CT-PA)into routine
clinical practice.

Deep vein thrombosis

Triads of Virchows
Venous stasis
Hyper coagulation status
Endothelial disease
other predisposing
conditions
Advanced age
Obesity
Pregnancy
Oral conraceptive use
History of previous pulmonary
embolism
Constrictive clothing

 Originate

primarily from Deep

Venous System of lower
extrimities.
Ilio-femoral thrombi and pelvic
viens appear to be the most
clinically recognized sources.
Air,amniotic fluid and fat emboli
are lower causes.

PE

Classification

ACUTE
CHR0NIC
Massive

Submassive

of

Patients with acute PE typically

develop signs and symptoms
immediately after obstruction
of pulmonary vessels.
Patients with chronic PE tend to
develop slowly progressive
dyspnea over a period of years
due to pulmonary hypertension.
Massive pe causes hypotension
.defined as systolic blood
pressure <90mmhg or drop in
systolic blood pressure of >40
mmHg from baseline for a
period >15 minutes.

All acute PE not meeting the

definition of massive PE are
considered submassive PE.

Symptoms
Dyspnea
Chest pain
Cough
Hemoptysis
Diaphoresis
Anxiety

Signs
Tachypnea
Tachtcardia
Cyanosis
Collapse
Circulatory
instability
Jugular venous
distension

Clinical assessment for

Pulmonary Embolism

Clinical symptoms of DVT

Other diagnosis less likely than
PE

3 points
3

Heart rate >100

1.5

Immobilization (>3 days)or

surgery in the previous 4
weeks

1.5

Previous DVT/PE

1.5

Hemoptysis

Malignancy

(Wells criteria)

Probability

Score

High

>6

Moderate

2 to 6

low

<2

Simplified clinical
probability

Chest Radiography
Atelectasis

or a pulmonary
parenchymal abnormality .
Pleural effusion.
12% of the chest radiographs in
patients with PE were interpreted
as normal.

Elctrocardiography.
Sinus tachycardia.
Right bundle branch block.
Precordial T-wave inversion and
ST segment changes.

Arterial Blood Gas

ABGs

usually reveal hypoxxemia

,hypocapnia and respirayory
alkalosis.

Echocardiography
Only 30 to 40 percent of patients
with PE have echocardiographic
abnormalities.
Increased right ventricular size.
Decreased RV function.
Tricuspid regurgitation.

Ventilation Perfusion(V/Q)Scan

Diagnostic accuracy was greatest

when the V/Q
scan
was combined with clinical
probability
which was determined by the clinician
prior
to the V/Q scan.
Patients
with
high
clinical
probability of PE and a high
probability v/q scan had a 95%
likelihood of having PE.
Patients with low clinical probability
of PE and a low probability v/q scan
had only a 4% likelihood of having
PE.

normal V/Q scan exclude PE.

lower extremity doppler
Lower extremity venous
ultrasound is sometimes
performed during the diagnostic
evaluation of PE.The rationale is
that venous thrombosis detected
by ultrasound.

Pulmonary Angiography
Pulmonary angiography is a
procedure that uses a special die
{contrast material} and xray to
see how blood flows through the
lungs.
Procedure
It is performed by a injecting
contrast into a pulmonary artery
branch after percutaneous
catheterization,usually via the
femoral vein.A filling defect or
abrupt cutoff of a small vessel is
indicative of an embolus.

Risk
Allergic reaction to contrast.
Damage to the blood vessels as
the needle and catheter are
inserted.
Excessive bleeding or blood
clots.
Heart attack or strock.
Injury to nerve.
Kidney damage from contrast.

CT Pulmonary Angiography(CTPA)
Spiral

CT scannig with
intravenous contrast is a
commonly used diagnostic
modality for a patients with
suspected PE.
One of the most commonly cited
benefits of CT-PA is its ability to
detect alternative pulmonary
abnormality .

Specificity
Availabity
Safety
Relative
rapidity of
procedure
Diagnosis of
other disease
entities.
Advancing
technology

Expense
Not portable
Poor
visualization
of certain
regions.
Reader
expertise
required

AIM
Prevent death and morbidity
Reduse the incidence of
recurrence
Primary Treatment
Supplemental oxygen for
hypoxemia if the PE is small
Intravenous infusion lines
Hypotension treated by
ionotropes
Continuous ECG monitoring

Introduction

Anticoagulation is the main therapy

for acute PE.Its goal is to decrease
mortality by preventing reccurent
PE.
Initiation of Anticoagulant
Parenteral anticoagulant therapy
should be initiated in all patients
in whom acute PE has been
confirmed.
The efficiency of parenteral
anticoagulant therapy depends
upon achieving a therapeutic
level of anticoagulation with in
the 24 hours of treatment.

Options include
low molecular weight heparin
Intravenous unfractionated
heparin
Subcutaneous unfractionated
heparin

Low molecular weight heparin

recommend for
most haemodynamically
patients with PE
rather than IV UFH,S/C UFH
Dosing

formulation

Enoxaparin
Tinzaparin
Dalteparin
Nadroparin
Reviparin

Unfractionated Heparin
Indication
a.
b.
c.
d.

Persistent hypotension due to

PE
Increased risk of bleeding
Thrombolysis is being
considered
Concern about subcutaneous
absorption

Dosing
IV UFH
o Several protocols for the
administration of IVUFH.
o All of the protocols administer
the IVUFH by continuous infusion
.
o Weight based dosing protocol is
our clinical practice.
o Administering starting bolus of
80u/kg/hr

S/S UFH

SC UFH can be initiated with

intravenous bolus of 5000u.

Warfarin

The majority of oral

anticoagulants are vit.k
Antagonists,which supress
production of vit.k dependent
clotting factor.
Warfarin is the most common
and best vit.k antagonist.

Initiation
Warfarin

can be initiated on the

same day or after heparin is
begun.
Warfarin should be overlapped
with heparin for minimum of five
days and until the INR has been
with in the theraprutic range.

Dosing

Administering warfarin using an

initial dose of not more than 5mg
per day for first two days.

SUMMARY

For

haemodynamically stable
patients with confirmed or
suspected PE recommended ,
initial treatment with lmwh.
For patients with confirmed or
suspected PE ,severe renal failure
suggests UFH
For patients with confirmed or
suspected PE who have persistent
hypotension ,increased risk of
bleeding ,potential abnormal
subcutaneous absoption ,or
whom thrombolysis may be
performed suggest IV UFH

Warfarin therapy initiated at the

same time or after lmwh,ufh.
Recommended that warfarin dose
be adjusted to achieve an INR of
2.5.

Thrombolytic therapy also may

be used in treating PE.
options
Steptokinase
Urokinase
Alteplase
Anistreplase

Merits

Resolves

the thrombi or emboli

more quickely and restore more
normal hemodynamic functioning
of pulmonary circulation

Redusing pulmonary
hypertension
improving perfusion
,oxygenation,and cardiac out put.
Contraindication
CVA with in past 2 months
Active bleeding
Surgery with in 10 days of the
thromtic event
Recent labour and delivery
Trauma

Inferior vena cava filters provide

a screen in the inferior vena cava
,allowing blood to pass through
while large emboli from the
pelvis and lower extrimities are
blocked and fragmented befpre
reaching the lung.

Embolectomy
a) Catheter embolectomy
b) Surgical embolectomy

a)

Catheter
Embolectomy
Rheolytic embolectomy

Using a rheolytic embolectomy

catheter,embolectomy
accomplished by injecting
pressurized saline through the
catheters distal tip, which
macerates the emboli.

Suction embolectomy

Suction embolectomy involves

suctioning thrombus through a
large lumen catheter by manually
applying negative pressurewith
an aspiration syringe.

Thrombus fragmentation

Mechanical disruption of the

thrombus can be achieved by
manually rotating pigtail catheter

Surgical thrombolectomy

A surgical thrombolectomy is
rarely performed, patients with
massive PE.

Minimizing The Risk of Pulmonary

Embolism
A major responsibility of the nurse is to
identify patients at high risk for PE and to
minimize the risk of PE in all patients.
Therefore, the nurse must give attention to
conditions predisposing to a slowing of venous
return (i.e. prolonged immobilization,
prolonged periods of sitting/traveling, varicose
veins, spinal cord injury), hypercoagulability
due to release of tissue thromboplastin after
injury/surgery (i.e. pancreatic, GI, GU, breast,
or lung tumor, increased platelet count in
polycythemia), venous endothelial disease (i.e.
thrombophlebitis, foreign bodies such as
IV/central venous catheters)

Preventing Thrombus Formation.

The nurse:
encourages ambulation and active and passive
leg exercises to prevent venous stasis in
patients on bed rest and to help increase venous
flow.
discourages the patient against sitting or lying
in bed for prolonged periods, crossing the legs,
and wearing constricting clothing. Legs
discourages legs dangling or feet placed in a
dependent position while sitting on the edge of
the bed; instead, the patients feet should rest
on a chair.
Should not leave intravenous catheters in place
for prolonged periods.

 Assessing Potential For

Pulmonary Embolism. The nurse
should:
examine patients who are at risk for
developing PE for a positive Homans sign
(pain in the calf as the foot is sharply
dorsiflexed), which may or may not indicate
impending thrombosis of the leg veins. A
positive Homans sign may indicate DVT.

Monitoring Thrombolytic
Therapy. The nurse:
keeps the patient on bed rest
assesses vital signs Q2H.
ensures that tests to determine prothrombin
time or partial thromboplastin time are
performed 3 to 4 hours after the thrombolytic
infusion is started to confirm that the
fibrinolytic systems have been activated.
ensures that only essential venipunctures are
performed because of the prolonged clotting
time, and manual pressure is applied to any
puncture site for at least 30 minutes.
uses pulse oximetry to monitor changes in
oxygenation.
immediately discontinues the infusion if
uncontrolled bleeding occurs.

 Managing

Chest Pain. The

nurse:
Places the patient in a semi-Fowlers position
which is more comfortable for breathing.
continues to turn the patient frequently and
repositioning him to improve the ventilation
perfusion ratio in the lung.
Administers opioid analgesics as prescribed for
pain.

 Managing

Oxygen Therapy.

The nurse:
gives careful attention the proper use of oxygen
and ensures that the patient understands the
need for continuous oxygen therapy.
assesses the patient frequently for signs of
hypoxemia and monitors the pulse oximetry
values to evaluate the effectiveness of the
oxygen therapy.
encourages deep breathing and performs
incentive spirometry to minimize or prevent
atelectasis and improve ventilation.

 Managing

Anxiety. The

nurse:
encourages the stabilized patient to talk about
any fears or concerns related to this frightening
episode.
answers the patients and familys questions
concisely and accurately.
explains the therapy, and describes how to
recognize untoward effects early.