Exemplar 16.K PE - Pearson

Embolus

Blood, fat, or bubble of air that breaks off and travels from another part of the body (deep venous system) to the lung and prevents the heart from taking in oxygen

Thromboemboli

Created by a blood clot, develops in the deep venous system (illio-femoral thrombi or pelvis veins) or right side of heart, most frequent cause of PE

Pulmonary Embolism (PE)

Sudden blockage of a major artery in the lungs

Prevention - In Hospital

o Anticoagulants before or after surgery for at-risk patients o Compression stockings during surgery and/or pneumatic compression o Physical activity as soon as possible after surgery o Elevating legs during bedrest

Pharmacologic Therapy - Anticoagulant Therapy

o May be initiated prophylactically in high-risk patients with no evidence of PE o In patients with DVT or PE, administered to prevent further clotting, embolization § Heparin: bolus then infusion · Approximately 5 days · Until oral anticoagulant is fully effective § Warfarin · Started at same time as heparin · Requires 5-7 days to be fully effective § Risk of bleeding- notify healthcare provider for excessive bleeding or bruising o Fibrinolytic therapy for massive PE and hypotension § May not reduce mortality associated with PE § May reduce incidence of pulmonary hypertension after embolism

Clinical Manifestations - Fat Emboli (Non-Thrombotic Pulmonary Emboli)

o Sudden onset of cardiopulmonary, neurologic symptoms § Dyspnea § Tachypnea § Tachycardia § Confusion § Delirium § Decreased LOC

Clinical Manifestations - Symptoms usually begin suddenly and may include

o Sudden shortness of breath o Sharp chest pain, often aggravated by coughing or movement o Pain in your back o Cough with or without bloody sputum o Excessive sweating o Rapid pulse or breathing o Lightheadedness or passing out o Blue lips or nail beds

Clinical Manifestations - Recent Blood Clot in Leg, You May Experience

o Swelling of the affected leg o Leg pain or tenderness that may only occur when you are standing or walking o Increased warmth in the swollen or painful area of the affected leg o Redness or discoloration of your skin o Enlargement of superficial veins in the affected leg

Prevention - While Traveling

o Take breaks from sitting while traveling o Flex ankles while seated o Drink plenty of fluids o Wear support stockings

Pharmacologic Therapy - Key Point To Consider

· Anticoagulant therapy is commonly used to treat both older and younger adults with DVT to prevent PE · Drugs are administered in a similar fashion and at comparable doses in older and younger clients · Monitoring may occur more frequently in older adults.

Diagnostic Tests

· Chest x-ray · Computerized Tomography Angiogram (CTA) · Echocardiogram (Echo) · Ventilation Perfusing Lung Scanning (VQ Scan) · Ultrasound of your leg veins (Duplex) · Pulmonary Angiography · Blood tests: D-dimer, Troponin, BNP (brain natriuretic peptide - hormone) and arterial blood gas analysis

Non-Thrombotic PE Risk Factors

· Fat emboli are the most common nonthrombotic pulmonary emboli · A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation · Tumors, fat or bone marrow or air entering the circulation are a rarer non-thrombotic cause · These patients should continue to be monitored o Criteria indicating risk for PE § Pulse > 99 bpm § Pulse oximetry < 95% on room air § History of DVT or PE § Hemoptysis § Recent surgery or trauma requiring hospitalization § Cancer § Unilateral leg swelling or limb pain

Surgery

· Performed when anticoagulant therapy does not prevent recurrent emboli or is contraindicated · Umbrella-like filter inserted into inferior vena cava o Trap large emboli o Allow continued blood flow · Filter is inserted percutaneously via femoral or jugular vein

Overview

· Prompt treatment of DVT can save lives · The pulmonary artery provides deoxygenated blood to the capillaries that form respiratory membranes with the alveoli, and the pulmonary veins return newly oxygenated blood to the heart (left side) for further transport throughout the body · Effects of PE depend on size and the extent of blood flow obstruction · A PE always affects both perfusion and ventilation: o Occlusion of large pulmonary artery → reduced gas exchange o Lung tissue infarction (<10% of pulmonary emboli) o Obstruction of small segment of pulmonary circulation o Chronic or recurrent, possibly multiple, small emboli · Large PE in a pulmonary artery=sudden death (gas-exchange is greatly reduced or prevented) · Thrombus arising from a deep vein thrombosis · (DVT) of the leg · Travels through the bloodstream · Lodges in the lungs · PE is a MEDICAL EMERGENCY- 50% of deaths occur within two hours after emboli formation

Risk Factors

· Virchow's triad- (same as DVT) stasis of venous blood flow, vessel wall damage, altered blood coagulation · Prolonged immobility- like a hip or knee replacement surgery · Trauma- hip and femur fractures, surgery · Heart failure · Obesity · Advanced age · Women- contraceptives and estrogen hormone replacement, pregnancy or just had a baby · PE higher in Blacks than whites