UNIT III PULMONARY EMBOLISM Mrs Indumathi Lecturer YNC

UNIT III: PULMONARY EMBOLISM Mrs. Indumathi Lecturer YNC

Introduction • A Pulmonary embolism is a blockage in one of the blood vessels in the lungs. It happens when part, or all , of a blood clots blocks the blood supply to the lungs. A pulmonary embolism is a serious, potentially life threatening condition.

Definition • Pulmonary embolism refers to the obstruction of one or more pulmonary arteries by a thrombus originating usually in the deep veins of the legs, the right side of the heart or, rarely, an upper extremity, which becomes dislodged and is carried to the pulmonary vasculature.

Sources: v THROMBOTIC EMBOLI deep leg veins ( iliac, femoral & popliteal). v Right ventricle, upper extremities, pelvic veins. v NON-THROMBOTIC fat, tumors, amniotic fluid, air & foreign bodies.

Risk factors/ causes 1. Venous stasis q Prolonged immobilization q Prolonged sitting/ travelling q Varicose vein q Spinal cord injury 2. Hypercoagulability q Injury q Tumor q Increased platelet count

3. Venous endothelial disease qthrombophlebitis q. Vascular disease q. Foreign body- iv cannula 4. Certain disease status q. Heart disease q. Trauma – fracture of pelvis q. DM q. COPD

5. Other predisposing conditions q. Advanced age q. Obesity q. Pregnancy q. Oral contraceptive use q. Constrictive clothing

PATHOPHYSIOLOGY Due to a blood clot or thrombus Pulmonary artery obstructs Alveolar dead space increases Gas exchange impaired or no blood flow

Various substances release from the clot and surrounding area Causing constriction of regional blood vessels and bronchioles Increase pulmonary vascular resistance Ventilation – perfusion imbalance Increase in pulmonary artery pressure

Increase in right ventricular work to maintain pulmonary blood flow Right ventricular failure Decrease in cardiac output Decrease in systemic blood pressure shock

Clinical Manifestations • • Dyspnea, pleuritic chest pain, tachypnea. Cyanosis, Tachyarrhythmias Syncope, diaphoresis Circulatory collapse Pleural friction rub Infarction of lung, ischemic necrosis of lung

Symptoms of deep vein thrombosis • Pain • Swelling • Warmth of proximal or distal extremity • Skin discoloration • Superficial vein distention

Diagnosis Chest x-ray ECG Peripheral vascular studies ABG analysis Ventilation perfusion scan Spiral CT scan or CT pulmonary angiography (CTPA) • D- dimer assay ( blood test for evidence of blood clot) • Pulmonary arteriogram • • •

Angiogram

CT scan

Prevention ü Active leg exercises ü Early ambulation ü Use of elastic compressive stockings ü Anti coagulation therapy ü Sequential compression devices are used to prevent venous stasis through compression and relaxation of calf muscles ü Low molecular weight heparin eg: Enoxaparin is an alternative therapy

Management Emergency Management Goal is to stabilize cardiorespiratory status • Oxygen is administered to relieve hypoxemia, respiratory distress, and cyanosis. • An infusion is started to open an I. V. route for drugs and fluids. • Vasopressors, inotropic agents such as dopamine (Intropin) • Antidysrhythmic agents may be indicated to support circulation if the patient is unstable.

Contd… • ECG is monitored continuously for rightsided heart failure • Indwelling urinary catheter to monitor urine output • Intubation and mechanical ventilation • Small doses of IV Morphine or sedatives

Pharmacological therpay Anticoagulation therapy : • I. V. heparin. – Heparin is used to limit the growth of the embolized thrombus and prevent reembolization by inhibiting coagulation and preventing deposition of new clots – I. V. loading dose 5000 units usually followed by continuous pump or drip infusion or given intermittently every 4 to 6 hours.

– Dosage adjusted to maintain the partial thromboplastin time (PTT) at 1. 5 to 2 times the pretreatment value – Protamine sulfate may be given to neutralize heparin in event of severe bleeding. • Oral anticoagulation with warfarin is usually used for follow-up anticoagulant therapy after heparin therapy has been established

Thrombolytic therapy • Eg: streptokinase, urokinase, are used in patients who are severely compromised ( hypotensive, hypoxemia despite O 2 therapy). • Thrombolytic therapy helps to dissolve the clot, thereby reducing pulmonary hypertension, improving pulmonary perfusion, oxygenation and CO. • Side effect bleeding

• Before treatment, INR, PTT, hematocrit and platelet counts are obtained. • Heparin is stopped prior to thromolytic therapy. • During therapy, invasive procedures are avoided unless needed

Surgical Intervention • Interruption of vena cava reduces channel size to prevent lower extremity emboli from reaching lungs. Accomplished by: – Ligation or clipping of the inferior vena cava to divide lumen into small channels without occluding the blood flow. – Placement of transvenously inserted intraluminal filter in inferior vena cava to prevent migration of emboli; inserted through femoral or jugular vein by way of catheter.

Embolectomy: • Is indicated if the patient has massive PE or has hemodynamic instability or if there any contraindications to thrombolytic therapy. • It involves removal of the clot on cardiopulmonary bypass machine. • The procedure has high mortality rate and high post operative complications.

CAVAL FILTER

NURSING MANAGEMENT: a) Minimize the risk of PE: • Assess patient history, family history and medication record. Ask patient about pain or discomfort in extremities. Assess the extremities for redness, warmth or inflammation. b)Prevent thrombus formation: • Ambulation and leg exercises to prevent venous stasis. • Pumping leg exercises to increase venous flow. • Advise not to sit or lie on bed for prolonged periods, not to cross legs and not to wear constrictive clothing.

Contd c)Monitoring thrombolytic therapy d)Managing pain e)Managing O 2 therapy: • Assess for hypoxemia, monitor saturation levels. • Deep breathing and incentive spirometry to minimize or prevent atelectasis. • Nebulization and postural drainage to manage secretions

f)Relieving anxiety g)Monitor for complications: -Cardiogenic shock -Right ventricular failure h)Provide post op care i)Patient education

NURSING DIAGNOSIS: 1. Ineffective breathing pattern related to tracheobronchial obstruction by blood clot, copious secretions, decreased lung expansion and inflammatory process. 2. Impaired gas exchange related to altered blood flow to alveoli or major portion of the lung, atelectasis, alveolar collapse, pulmonary edema and excess secretions.

3. Ineffective tissue perfusion: cardiopulmonary peripheral, cerebral related to impaired blood flow, alveolar perfusion and gas exchange impairment, occlusion of pulmonary artery, hypoxemia and increased cardiac workload. 4. Fear and anxiety related to severe dyspnea, perceived threat of death, physiologic response to hypoxemia, unknown outcome of situation.

Patient Education and Health Maintenance • Advise patient of the possible need to continue taking anticoagulant therapy for 6 weeks. • Teach about signs of bleeding, especially of gums, nose, bruising, blood in urine and stools. • For patients on anticoagulants, instruct to use soft toothbrush, avoid shaving with blade razor (use electric razor instead) • Avoid aspirin-containing products. • Notify health care provider of bleeding or increased bruising.

• Warn against inactivity for prolonged periods or sitting with legs crossed to prevent recurrence. • Encourage wearing a Medic. Alert bracelet identifying patient as anticoagulant user. • Instruct patient to lose weight if applicable; obesity is a risk factor for women. • Discuss contraceptive methods with patient if applicable; females with history of pulmonary embolus are advised against taking hormonal contraceptives