What is a blockage of a pulmonary artery by foreign matter?
The obstruction may be fat, air, tumor tissue, or a thrombus that usually arises from a peripheral vein (most frequently arising from the deep veins of the legs)
A blood clot that forms and remains in a vein is called what?
A blood clot that becomes dislodged and travels to another part of the body is called what?
Embolus may originate from one large thrombus or occur as a series of small thrombi and may or may not interfere with what?
the right side of the heart's ability to perfuse the lungs adequately
If Blockage of the pulmonary vascular system is significant blood flow restricted leading to what?
- Pulmonary infarction
- Alveolar atelectasis
- Alveolar consolidation
- Tissue necrosis
Can a pulmonary embolism cause bronchoconstriction or bronchospasm?
- Exact mechanism not known. Maybe release of histamine, prostoglandin or other cellular mediators
The most common cause of pulmonary blood clots for Pulmonary Embolism originate�or break away from�?
deep vein thrombus (DVT)
What are other possible causes of thrombosis or embolism?
- Amniotic fluid
- Bone marrow
- Tumor fragments
What does Virchow's triad include?
- Blood Flow
with Thrombosis being in the middle
Blood clot formation is due to three things, what are they?
- Blood � the increased tendency of blood to form clots
- Vessel Wall � injury to the endothelial cells that line the vessels
- Blood Flow � slowing or stagnation of blood flow through the veins
Blood � the increased tendency of blood to form clots is referred to as what, and what usually will caused this?
- Deficiencies of anticoagulants
- Increases in clotting factors in the blood
- Prothrombin G20210A
How does Vessel Wall pertain to the formation of a thrombus?
injury to the endothelial cells that line the vessels
What produce chemicals that inhibit the clotting of platelets inside the vessels?
Breakdown or absence of the cells allows clots to form in its place.
epithelial cells; from endothelium
How does Blood Flow pertain to the formation of a thrombus?
- slowing or stagnation of blood flow through the veins
- If blood flow slows (venous stasis) it allows platelets more time in contact with endothelium making it more likely that clots may form
How is Venous stasis a risk factor for Pulmonary Embolism?
- Inactivity (most common)
- Prolonged bed rest
- Prolonged sitting
- Congestive heart failure
- Varicose veins
How do Surgical Procedures pertain to Pulmonary Embolism? (name examples)
It is a risk factor
- Hip surgery
- Pelvic surgery
- Knee surgery
- - these last three are most important because they limit mobility for extended amount of time
- Certain obstetric or gynecologic procedures
How does Trauma pertain to pulmonary embolism? (name examples)
- Bone fractures
- Extensive injury to soft tissue
- Postoperative or postpartum states
- Extensive hip or abdominal operation
- Phlegmasia alba dolens puerperarum
How do Hypercoagulation disorders pertain to pulmonary embolism? (name examples)
- Oral contraceptives
- Multiple myeloma
What are Other risk factors for Pulmonary Embolism?
- Pacemakers or venous catheters
- Pregnancy and childbirth
- Supplemental estrogen
- Family history of venous thromboembolism
- Malignant neoplasm
What are common symptoms of a Pulmonary Embolism?
- Sudden shortness of breath
- Weak pulse
- Lightheadedness or fainting
- Excessive sweating
- Cool or clammy skin to the touch
What does the folllowing describe?
Chest pain that resembles a heart attack
signs and symptoms of Pulmonary Embolism
How are chest x-rays used for recognition of a pulmonary embolism?
often normal but used to rule out conditions with same symptoms
What has become the first line test for diagnosis because offers 3-D view and accurately identifies abnormalities
Spiral (helical) Computerized Tomography (CT) Scan
For a pulmonary embolism, what are common findings with an Electrocardiogram (ECG)?
commonly see nonspecific ST-T wave changes but may see A-Fib and A-Flutter as well
What will only be reliable if condition of Pulmonary Embolism is extreme?
Ventilation/Perfusion Scan (V/Q scan)
What provides clear image of blood flow and very accurate but not used due to time requirements and invasiveness?
What are additional test used to detect blood clots in veins? (DDEMMB)
- D-dimer Blood Test (fibrinogen test) � simple test used to test for protein fibrinogen which is essential in clotting. Values higher than 500 ng/mL are considered positive
- Duplex Venous Ultrasonography � noninvasive and very accurate for more superficial clots but not DVT�s
- Extremity Venography � more complex (uses catheters and dyes) and invasive than duplex venous ultrasonography
- Magnetic Resonance Imaging (MRI) � useful when CT is not an option such as pregnancy and allergies to dyes used for contrast
- Magnetic Resonance Angiography (MRA) � used to differentiate between blood and clots
- Blood Tests � used to determine if there any inherited abnormalities (i.e. family history of clots, more than one episode of clots, clots forming for no know reason)
What are clinical manifestations resulting from the pathophysiologic mechanisms caused (or activated) by Pulmonary Embolism?
What vital signs accompany Pulmonary Embolism?
- Increased RR - stimulated by the pulmonary baroreceptors
- Increased heart rate (pulse)
- Systemic hypotension
What might you see upon physical examination of a person with a Pulmonary Embolism?
- Cough and hemoptysis
- Peripheral edema and venous distention
- Distended neck veins
- Swollen and tender liver
- Chest pain/decreased chest expansion
- Syncope, light-headedness, and confusion
D-dimer Blood Test (fibrinogen test) � simple test used to test for protein fibrinogen which is essential in clotting. Values higher than what are considered positive?
What abnormal heart sounds might you hear with Pulmonary Embolism? (part of physical exam)
- Abnormal heart sounds
- Increased second heart sound (S2) due to increased pressure in the pulmonary artery � valve closes more forcefully
- Increased splitting of the second heart sound (S2) sometimes noted due to either (1) pulmonary hypertension or (2) incomplete right bundle branch block (delay of signal sent to right slowing contraction)
- Third heart sound (or ventricular gallop) � exact cause unknown
What is a consequence of increased pulmonary blood pressure due to strain or hypertrophy causes a sustained lift on the left lower portion of the sternum? (part of physical exam)
Right ventricular heave or lift
A right ventricular lift can be detected in patients with a pulmonary embolism if significant pulmonary hypertension is present. When will it be felt?
Felt during systole
What are the Chest Assessment Findings with Pulmonary Edema?
- Pleural friction rub (especially when pulmonary infarction involves the pleura)
What type of blood gas will be seen with mild to moderate stages of Pulmonary Embolism?
pH increased, PaCO2 decreased, HCO3 N or decreased (slightly), PaO2 decreased
What type of blood gas will be seen with severe stages of a Pulmonary Embolism?
pH decreased, PaCO2 increased, HCO3 increased (slightly), PaO2 decreased
What will the oxygen indicies look like with Pulmonary Embolism?
same as always, Qs/Qt O2ER up, DO2 SvO2 down, VO2 C(a-v)O2 normal
What will the hemodynamic indicies look like with Pulmonary Embolism?
- severe right side increase, left side decrease
- Increased: CVP RAP PA PCWP(or N) RVSWI PVR
- Decreased: CO SV SVI CI LVSWI
- Normal: SVR
There is no single ECG pattern diagnostic of pulmonary embolism.
Abnormal patterns only suggest the possibility of pulmonary embolic disease, and include what?
- Sinus tachycardia (Most common)
- Atrial arrhythmias
- - Atrial tachycardia
- - Atrial flutter
- - Atrial fibrillation
- Acute right ventricular strain pattern and right bundle branch block
- P-pulmonale (peaked p-wave)
- - Tall, narrow P-waves associated with Cor Pulmonale
Patients with a pulmonary embolus often demonstrate no radiographic signs.
However, some findings may include what?
- Increased density (in infarcted areas)
- Hyperradiolucency distal to the embolus
- Dilation of the pulmonary arteries
- Pulmonary edema
- Right ventricular cardiomegaly (cor pulmonale)
- Pleural effusion (usually small)
What are the management options for Pulmonary Embolism?
- Fast-acting anticoagulant - heparin
- Slow-acting, oral anticoagulant
- Thrombolytic agents
- Preventive measures
- Pulmonary emblolectomy
Fast-acting anticoagulant - heparin - is divided into what two categories?
- High-molecular weight heparin
- - Unfractionated heparin
- - Until recently, mainstay
- - Possible bleeding can occur
- Low-molecular weight heparins
- - Recently available and shown to be safer and more cost effective
- a. Enoxaparin
- b. Dalteparin
- c. Tinzaparin
What Slow-acting, oral anticoagulants?
- Can be taken prevenatively at home
- - Coumadin
- - Panwarfin
What do Thrombolytic agents do?
- Actually dissolves the clot
- - Streptokinase
- - Urokinase
- - Alteplase
- - reteplase
- Sometimes used in conjunction with heparin but not solely for treating PE due to severe bleeding risk.
What are some Preventive measures of a Pulmonary Embolism?
- Exercise while seated
- Drink fluids
- Graduated compression stockings
- Vein filter
- Pneumatic compression
What is a Pulmonary emblolectomy?
Surgical removal of clots
What are the respiratory care tx protocols for a Pulmonary Embolism?
- Oxygen Therapy Protocol
- - Used to decrease WOB and improve oxygenationi during shunting and dead spacing
- Aerosolized Medication Protocol
- - Used to counter act bronchoconstriction or bronchospasm that may be occurring