Pulmonary embolism

1. Pulmonary Embolism Pulmonary Embolism
DR / DR / Amany lotfyAmany lotfy

2. Pulmonary embolism (PE)Pulmonary embolism (PE)
refers to the obstruction of the refers to the obstruction of the
pulmonary artery or one of its pulmonary artery or one of its
branches by a thrombus (or thrombi) branches by a thrombus (or thrombi)
that originates somewhere in the that originates somewhere in the
venous system or in the right side of venous system or in the right side of
the heart the heart

3. Causes Causes
1.thrombous 1.thrombous
2. embolism 2. embolism
3.trauma 3.trauma
4. surgery 4. surgery
5. hypercoaguability5. hypercoaguability
6. heart failure 6. heart failure
7. pregnancy ( increase coaguability of BL7. pregnancy ( increase coaguability of BL
8. older than 50 years 8. older than 50 years
9. atrial fibrillation 9. atrial fibrillation

4. Pathophysiology Pathophysiology
-When a -When a thrombus completely or partially thrombus completely or partially
obstructs a pulmonary arteryobstructs a pulmonary artery or its or its
branches, branches,
the alveolar dead space is increasedthe alveolar dead space is increased. The . The
area, although continuing to be ventilated, area, although continuing to be ventilated,
receives receives little or no blood flowlittle or no blood flow. Thus, . Thus, gas gas
exchange is impairedexchange is impaired or absentor absent in this in this
area.area.

5. PathophysiologyPathophysiology
-In addition, various -In addition, various substances are substances are
released from the clotreleased from the clot and surrounding and surrounding
area, area, causing regional blood vessels and causing regional blood vessels and
bronchioles to constrict.bronchioles to constrict.
 This causes an This causes an increase in pulmonary increase in pulmonary
vascular resistance.vascular resistance. This reaction This reaction
compounds (compounds (the ventilation–perfusion the ventilation–perfusion
imbalance.)imbalance.)

6. PathophysiologyPathophysiology
-The hemodynamic consequences are -The hemodynamic consequences are
increased pulmonary vascular resistanceincreased pulmonary vascular resistance
from the regional vasoconstriction and from the regional vasoconstriction and
reduced size of the pulmonary vascular reduced size of the pulmonary vascular
bed. bed.
This results in an This results in an increase in pulmonary increase in pulmonary
arterial pressurearterial pressure and, in turn, an and, in turn, an increase increase
in right ventricular workin right ventricular work to maintain to maintain
pulmonary blood flow. Whenpulmonary blood flow. When

7. PathophysiologyPathophysiology
the work requirements of the right the work requirements of the right
ventricle exceed its capacity,ventricle exceed its capacity,
 right ventricular failureright ventricular failure occurs, occurs,
leading to a leading to a decrease in cardiac decrease in cardiac
outputoutput followed by a followed by a decrease in decrease in
systemic blood pressuresystemic blood pressure and the and the
development of development of shock.shock.

8. RISK FACTORSRISK FACTORS
Venous Stasis (slowing of blood flow in Venous Stasis (slowing of blood flow in
veins)veins)
-Prolonged immobilization (especially -Prolonged immobilization (especially
postoperative)postoperative)
-Prolonged periods of sitting/traveling-Prolonged periods of sitting/traveling
-Varicose veins-Varicose veins
-Spinal cord injury-Spinal cord injury
-Hypercoagulability (due to release of tissue -Hypercoagulability (due to release of tissue
thromboplastin after injury/surgery) thromboplastin after injury/surgery)
--InjuryInjury
-Tumor (pancreatic, GI,, breast, lung)-Tumor (pancreatic, GI,, breast, lung)
-Increased platelet count (polysalathemia, -Increased platelet count (polysalathemia,
splenectomy splenectomy

9. RISK FACTORS RISK FACTORS

--Venous Endothelial DiseaseVenous Endothelial Disease
-Thrombophlebitis -Vascular disease-Thrombophlebitis -Vascular disease
-Foreign bodies (IV/central venous -Foreign bodies (IV/central venous
catheters)catheters)
-Certain Disease States -Certain Disease States
(combination of stasis, coagulation (combination of stasis, coagulation
alterations, and venous injury)alterations, and venous injury)
-Heart disease (especially heart failure)-Heart disease (especially heart failure)
-Trauma (especially fracture of hip, pelvis, -Trauma (especially fracture of hip, pelvis,
vertebra, lower extremities)vertebra, lower extremities)

10. RISK FACTORSRISK FACTORS
-Postoperative state/postpartum period-Postoperative state/postpartum period
-Diabetes mellitus -Diabetes mellitus
-Chronic obstructive pulmonary disease c -Chronic obstructive pulmonary disease c
o p Do p D
--Other Predisposing ConditionsOther Predisposing Conditions
-Advanced age -Obesity -Pregnancy-Advanced age -Obesity -Pregnancy
-Oral contraceptive use -Constrictive -Oral contraceptive use -Constrictive
clothingclothing
--History of previousHistory of previous thrombophlebitis, thrombophlebitis,
pulmonary embolismpulmonary embolism

11. Clinical ManifestationsClinical Manifestations
1.1.DyspneaDyspnea is the most frequent symptom; is the most frequent symptom;
tachyapneatachyapnea (very rapid respiratory rate) is (very rapid respiratory rate) is
the most frequent sign . the most frequent sign . The duration and The duration and
intensity of the dyspnea depend on the intensity of the dyspnea depend on the
extent of embolization.extent of embolization. Chest painChest pain is is
common and is usually sudden and common and is usually sudden and
pleuritic. It may be pleuritic. It may be substernal and substernal and
misdiagnosed with angina pectoris or a misdiagnosed with angina pectoris or a
myocardial infarction.myocardial infarction.
- - Other symptomsOther symptoms include anxiety, fever, include anxiety, fever,
tachycardia, apprehension, cough, tachycardia, apprehension, cough,
diaphoresis, hemoptysis, and syncope.diaphoresis, hemoptysis, and syncope.

12. Assessment and Diagnostic Assessment and Diagnostic
FindingsFindings

--The diagnostic workup includes aThe diagnostic workup includes a
- ventilation–perfusion scan,- ventilation–perfusion scan,
-pulmonary angiography, -pulmonary angiography,
-chest x-ray-chest x-ray
-, ECG, -, ECG,
-peripheral vascular studies, and arterial -peripheral vascular studies, and arterial
blood gas analysis.blood gas analysis.
-Doppler ultrasonography and venography-Doppler ultrasonography and venography

13. PreventionPrevention
prevent deep venous thrombosis. prevent deep venous thrombosis.
1. active leg exercises 1. active leg exercises
2. The intermittent pneumatic leg 2. The intermittent pneumatic leg
compression device ( reduces venous compression device ( reduces venous
stasis). stasis).
3. use of elastic compression stockings 3. use of elastic compression stockings
4. anticoagulant therapy 4. anticoagulant therapy

14. Medical ManagementMedical Management
• • General measures to improve respiratory General measures to improve respiratory
and vascular statusand vascular status
• • Anticoagulation therapyAnticoagulation therapy
• • Thrombolytic therapyThrombolytic therapy
• • Surgical interventionSurgical intervention

15. GENERAL MANAGEMENTGENERAL MANAGEMENT

--Oxygen therapyOxygen therapy is administered to correct is administered to correct
the hypoxemia, relieve the pulmonary the hypoxemia, relieve the pulmonary
vascular vasoconstriction, and reduce the vascular vasoconstriction, and reduce the
pulmonary hypertension. pulmonary hypertension.
--Using elastic compression stockingsUsing elastic compression stockings or or
intermittent pneumatic leg compression intermittent pneumatic leg compression
devices reduces venous stasis. devices reduces venous stasis.

16. GENERAL MANAGEMENTGENERAL MANAGEMENT
-These measures compress the -These measures compress the
superficial veins and increase the superficial veins and increase the
vesecosity of blood in the deep vesecosity of blood in the deep
veins by veins by redirecting the blood redirecting the blood
through the deep veinsthrough the deep veins..
 Elevating the legElevating the leg (above the level (above the level
of the heart) also increases of the heart) also increases
venous flow.venous flow.

17. Anticoagulation TherapyAnticoagulation Therapy

.. Anticoagulant therapy (heparin, Anticoagulant therapy (heparin,
warfarin sodium)warfarin sodium)
has traditionally been the primary has traditionally been the primary
method for managing acute deep vein method for managing acute deep vein
thrombosis and PE thrombosis and PE

18. Anticoagulation TherapyAnticoagulation Therapy
HeparinHeparin is used to is used to prevent recurrence of prevent recurrence of
emboli but has no effect on emboli that are emboli but has no effect on emboli that are
already present.already present.
It is administered as an It is administered as an intravenous bolusintravenous bolus
of of 5,000 to 10,000 units5,000 to 10,000 units, followed by a , followed by a
continuous infusion initiated at a dose of continuous infusion initiated at a dose of
18 U/kg per hour, not to exceed 1,600 18 U/kg per hour, not to exceed 1,600
U/hourU/hour

19. Thrombolytic TherapyThrombolytic Therapy
-Thrombolytic therapy (urokinase, strepto--Thrombolytic therapy (urokinase, strepto-
kinase, alteplase, anistreplase, reteplase) kinase, alteplase, anistreplase, reteplase)
also may be also may be used in treatingused in treating
PE, particularly in patients who are PE, particularly in patients who are
severely compromised (eg, those who are severely compromised (eg, those who are
hypotensivehypotensive and have significant and have significant
hypoxemiahypoxemia despite oxygen despite oxygen
supplementation). supplementation).
--

20. Thrombolytic TherapyThrombolytic Therapy
Thrombolytic therapyThrombolytic therapy
resolves the thrombi or emboli more resolves the thrombi or emboli more
quicklyquickly
restores more normal hemodynamic restores more normal hemodynamic
functioning of the pulmonary circulation, functioning of the pulmonary circulation,
Reducing pulmonary hypertensionReducing pulmonary hypertension
Improving perfusion, oxygenation, and Improving perfusion, oxygenation, and
cardiac output.cardiac output.

21. SURGICAL MANAGEMENTSURGICAL MANAGEMENT
--Pulmonary embolectomyPulmonary embolectomy requires a requires a
thoracotomy with cardiopulmonary by- thoracotomy with cardiopulmonary by-
pass technique.pass technique.
--Transvenous catheter embolectomy is a is a
technique in which a vacuum-cupped technique in which a vacuum-cupped
catheter is introduced transvenously into catheter is introduced transvenously into
the affected pulmonary artery. Suction is the affected pulmonary artery. Suction is
applied to the end of the embolus and the applied to the end of the embolus and the
embolus is aspirated into the cupembolus is aspirated into the cup. .

22. Nursing ManagementNursing Management
MINIMIZING THE RISK OF MINIMIZING THE RISK OF
PULMONARY EMBOLISMPULMONARY EMBOLISM
PREVENTING THROMBUS PREVENTING THROMBUS
FORMATIONFORMATION
ASSESSING POTENTIAL FOR ASSESSING POTENTIAL FOR
PULMONARY EMBOLISMPULMONARY EMBOLISM
MONITORING THROMBOLYTIC MONITORING THROMBOLYTIC
THERAPYTHERAPY
MANAGING PAINMANAGING PAIN

23. Nursing management Nursing management
MANAGING OXYGEN THERAPYMANAGING OXYGEN THERAPY
RELIEVING ANXIETYRELIEVING ANXIETY
MONITORING FOR MONITORING FOR
COMPLICATIONSCOMPLICATIONS
PROVIDING POSTOPERATIVE PROVIDING POSTOPERATIVE
NURSING CARENURSING CARE
PROMOTING HOME AND PROMOTING HOME AND
COMMUNITY-BASED CARECOMMUNITY-BASED CARE

24. Mention nursing process of patient have Mention nursing process of patient have
Pulmonary Embolism ? Pulmonary Embolism ?
DEFINE the following?DEFINE the following?
thrombus thrombus
Embolism Embolism
Pulmonary vascular resistancePulmonary vascular resistance
-Pulmonary arterial pressure-Pulmonary arterial pressure
-The intermittent pneumatic leg compression -The intermittent pneumatic leg compression
device device
-Cardiopulmonary by pass technique-Cardiopulmonary by pass technique

25. Thank youThank you