Pulmonary embolism

 (PE) refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that
originates somewhere in the venous system or in the right side of the heart
 PE is due to a blood clot or thrombus. However, there are other types of emboli: air, fat, amniotic
Fluid, and septic (from bacterial invasion of the thrombus).

Etiology and risk factors

 Most pulmonary emboli originate in the deep veins of the lower extremities (deep vein thrombosis, or
DVT)
 surgical procedures done under general anesthesia
 heart failure
 fractures of the lower extremities
 bed rest
 obesity
 Previous history of DVT or PE.
 fat emboli from compound fractures
 amniotic fluid embolism during labor and delivery
 Air embolism from entry of air into the bloodstream.
Pathophysiology
Blood clot that has traveled into a pulmonary artery.
Resulting obstruction of blood flow causes a ventilation-perfusion mismatch, which in this case means that an area
of the lung is well ventilated with air but has no blood flow, or perfusion. Because reduced or no blood supply is
available to pick up the oxygen in the affected portion of the lung, it becomes pulmonary “dead space,” causing
seriously impaired gas exchange. Occasionally damage occurs to a portion of the lung because of lack of oxygen.
This is called lung infarction.
Clinical features
 Sudden onset of dyspnea for no apparent reason.
 The patient may be gasping for breath and may appear anxious.
 Tachycardia, tachypnea, and cough may be present.
 Auscultation may reveal crackles or a friction rub.
 If lung infarction has occurred, hemoptysis and pleuritic chest pain may also be present.
 Some patients have no symptoms at all.
Complications
 High blood pressure within the pulmonary circulation (pulmonary hypertension) may result from arterial
occlusion and lead to right ventricular failure. This occurs because the right ventricle is unable to push blood
into the occluded artery. As a result, the contraction becomes weak, cardiac output falls, and the patient
becomes hypotensive
Diagnostic Tests
 A spiral CT scan is a new and fast type of CT scan that is noninvasive and can diagnose PE quickly. If this is
not
 Lung scan (ventilation-perfusion scan) is done to assess the degree of ventilation of lung tissue and the areas of
blood perfusion. If an area is well ventilated but poorly perfused (i.e., a mismatch), PE is suspected.
 A pulmonary angiogram can outline the pulmonary vessels with a radiopaque dye injected via a cardiac
catheter. This can show where blood flow is diminished or absent, suggesting an embolism.
 Chest x-ray examination
 electrocardiogram (ECG)
 arterial blood gas analysis
 magnetic resonance imaging
 (MRI)
Medical Treatment
1. thrombolytic therapy
 Streptokinase, urokinase, and tissue plasminogen activator (t-PA), dissolve clots and are very
effective.
  However, they must be used within 4 to 6 hours of the clot’s occurrence and are associated with a
risk for hemorrhage.
2. Heparin, a potent anticoagulant medication, is administered via continuous intravenous infusion.
Sometimes an intermittent IV or subcutaneous route is used. Heparin is never given intramuscularly
because of the risk of hematoma development. Clotting studies (partial thromboplastin time [PTT] or
thrombin clotting time [TCT]) are monitored and maintained at 1.5 to 2 times the control value.
3. Oxygen is administered as ordered.
4. Intubation and mechanical ventilation may be required in some cases.
5. Warfarin sodium, an oral anticoagulant, is used for approximately 12 weeks following the embolism to
prevent recurrence. Warfarin therapy can be initiated 2 to 3 days after the initiation of heparin therapy.
6. If clots are a recurring problem, a filter may be placed into the inferior vena cava via the jugular or femoral
vein. One filter that is commonly used is the Greenfield filter, which filters out clots traveling from the
lower extremities toward the heart and lungs.
7. Surgical embolectomy can be performed.
Prevention
 Prevention of thrombi in the deep veins of the legs is the most important factor in the prevention of a
pulmonary embolism.
 Regular ambulation is advised if the patient is able.
 If a patient is at risk for DVT or PE, low-dose heparin, enoxaparin, warfarin (Coumadin), or intermittent
compression stockings are used to prevent thrombus formation.
 If a DVT is diagnosed, prompt treatment is essential to prevent a PE.