CONCEPT OF PERFUSION:
PULMONARY EMBOLISM
BY: LISA HOSEY RN, MSN
PULMONARY EMBOLISM (PE)
• Obstruction of the pulmonary artery or one of its branches by a thrombus or
thrombi that originates somewhere in the venous system or right side of heart.
• DVT – most common cause
• What are signs and symptoms of a DVT?
• Thromboembolism
• Associated with trauma, abdominal & orthopedic surgery, pregnancy, heart
failure, hypercoagulable states, prolonged immobility, age (over 50).
PATHOPHYSIOLOGY
• Blood clot or thrombus
• Emboli – air, fat, amniotic fluid, septic (bacterial invasion of thrombus)
• Little or no blood flow
• Impaired gas exchange or absent
• Increased pulmonary vascular resistance
• Right ventricular failure / possible atrial fibrillation
• Occlusion of outflow tract of main pulmonary artery or bifurcation of the pulmonary arteries
CLINICAL MANIFESTATIONS
• Dyspnea / Tachypnea • Cough / hemoptysis
• Chest pain • Pleural fraction rub – grating sounds with
• Anxiety auscultation
• Fever • Diaphoresis
• Tachycardia • Hemoptysis
• Apprehension / Restlessness • Syncope
• Hypotension • Shock
• Weak & rapid pulse • Sudden death
DIAGNOSTICS
• Chest x-ray, ECG, pulse oximetry,
ABG’s, V/P scans
• Pulmonary angiography
• CT
• D-Dimer
• Normal Client < or = to 250 ng/mL
• DVT or PE < or = to 500 ng/mL
PREVENTION
• Active leg exercises to avoid venous stasis
• Early ambulation
• Anti – embolism stockings
• Active & passive ROM exercises
• No leg crossing, no prolonged sitting
• Don’t dangle legs over side of bed
• Elevate extremities on bed
EMERGENCY MANAGEMENT OF
PULMONARY EMBOLUS
• Oxygen • Coagulation studies, CBC,
• Nasal cannula Electrolytes
• Endotracheal intubation / mechanical
ventilation • CT
• Notify provider • Urinary catheter
• IV • IV Morphine or sedative
• Pulse oximetry / ABG’s
• EKG
SURGICAL INTERVENTIONS
• IVC Filters
• Embolectomy / lung transplant
SURGICAL INTERVENTIONS
PHARMACOLOGY
•Anticoagulants
•Interfere with the clotting cascade and prolong blood clotting time
•No direct effect in a blood clot that has already formed. Wont break it up but will keep it from growing.
•Short term treatment or prophylaxis
•Long term prevention with high risk patients
•Antiplatelets
•Decrease platelet aggregation and inhibit thrombus formation
Clopidogrel (Plavix), Aspirin
PHARMACOLOGY
ANTICOAGULATION
• Heparin IV or SQ (monitor PT/PTT)
• Low molecular weight Heparin SQ
• Enoxaparin (Lovenox) (monitor platelets)
• Fondaparinux (Arixtra) SQ admin.
• Warfarin ( Coumadin) PO
• Oral Xa inhibitor
• Rivaroxaban (Xarelto)
• Dabigatran (Pradaxa)
PHARMACOLOGY
ANTICOAGULATION
• Long – term secondary phase
• 3 – 6 month regimen of long – term maintenance with Warfarin
• Monitor INR (2 – 3 while on Warfarin / Coumadin)
• What if INR is high? Adjust (lower) dose or administer vit. k via IV)
PHARMACOLOGY
THROMBOLYTIC (FIBRINOLYTIC) THERAPY
• Used in treating massive PE
• Alteplase (Activase, t-PA)
• Reteplase (Retavase)
• Resolves thrombi or emboli quickly & restores more normal hemodynamic function of
pulmonary circulation
• Bleeding is significant side effect
• Contraindications
• CVA, head bleeds, active bleeds, surgery within 10 days, recent L&D, any kind of recent trauma, and severe
hypertension
PHARMACOLOGY
THROMBOLYTIC (FIBRINOLYTIC) THERAPY
• Prior to therapy
• INR, PTT, hematocrit, platelets
• Stop anticoagulants
• During therapy
• Limited invasive procedures
• Replace blood loss & reverse bleeding tendency
• After therapy
• Initiate anticoagulants
NURSING MANAGEMENT
• Minimizing risk of PE (early ambulation, comp stockings, elevation,
• Preventing thrombus formation
• Assessing potential for PE
• Managing pain
• Managing oxygen therapy
• Relieving anxiety
PATIENT EDUCATION
ANTICOAGULANT THERAPY
• Need for continued anticoagulant therapy
• Avoid use of sharps (razors, knives). Use electric razors.
• Soft bristle toothbrush
• Do not take aspirin, NSAIDs or antihistamine with coumadin – notify provider of any OTC medications
• Avoid laxatives
• Monitor & report dark tarry stools
• Wear ID bracelet or carry medication card
• Walk or change positions with long travel
• Routine scheduled lab work to monitor coagulation studies
