PULMONARY

EMBOLISM
Contents

Diagnostic Nursing
Definition Causes Pathophysiology
Intervention
Test

Risk Sign and

Classification Management Prevention
Factors Symptoms
Definition • 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

• The cause is usually a blood clot in the leg called a deep vein
thrombosis that breaks, loose and travels through the
bloodstream to the lungs.

• It can damage part of the lungs due to restricted blood flow,

decrease oxygen levels in the blood, and affect other organs as
well. Large or multiple blood clots can be fatal.

• The blockage can be life-threatening.

 • Most commonly, pulmonary embolism is due to a blood
Classification clot or thrombus, but there are other types of emboli: fat,
air, amniotic fluid, and septic.
– Fat emboli. Fat emboli are cholesterol or fatty substances that
may clog the arteries when fatty foods are consumed more.

– Air emboli. Air emboli usually come from intravenous devices.

– Amniotic fluid emboli. Amniotic fluid emboli are caused by

amniotic fluid that has leaked towards the arteries.

– Septic emboli. Septic emboli originate from a bacterial invasion

of the thrombus.
 • Blood clots can form for a variety of reasons. Pulmonary
Causes embolisms are most often caused by deep vein thrombosis, a
condition in which blood clots form in veins deep in the body. The
blood clots that most often cause pulmonary embolisms begin in
the legs or pelvis.

• Blood clots in the deep veins of the body can have several
different causes, including:
– Injury or damage: Injuries like bone fractures or muscle tears can
cause damage to blood vessels, leading to clots.
– Inactivity: During long periods of inactivity, gravity causes blood to
stagnate in the lowest areas of your body, which may lead to a blood
clot. This could occur if you’re sitting for a lengthy trip or if you’re
lying in bed recovering from an illness.
– Medical conditions: Some health conditions cause blood to clot too
easily, which can lead to pulmonary embolism. Treatments for
medical conditions, such as surgery or chemotherapy for cancer, can
also cause blood clots.
 • Includes immobility, trauma to the legs, childbirth, congestive
Risk Factors heart failure, dehydration, increased coagulability of the blood, and
cancer

• Thrombi tend to break off with sudden muslce action or massage,

trauma, or changes in the blood flow

• Post operative risk can be reduced by early ambulation or use of

TEDS (thromboemobolic) stockings

• Other types include fat emboli from the bone marrow resulting
from fracture of a large bone, vegetations resulting from
endocarditis in the right side of the heart, amniotic fluid emboli
fr0m placental tears occuring during labor and delivery, tumor cell
emboli that break away from a malignant mass, or air embolus
injected into a vein.
Pathophysiology
• The effects of pulmonary embolus depend somewhat on the material but largely on
the size and therefore on the location of the obstruction.

• Because lung tissue is supplied with oxygen and nutrients by the bronchial
circulation, infarction does not follow obstruction of the pulmonary circulation unless
the general circulation is compromised or there is prior lung disease.

• Infarction usually involves a segment of the lung and the pleural membrane in the
area.
Small pulmonary emboli are frequently
“silent” or asymptomatic. However, multiple
small emboli (“a shower”) often have an
effect equal to that of a larger embolus

Emboli that block moderate-sized arteries

usually causes respiratory impairment
because fluid and blood fill the alveoli of the
involved area. Reflex vasoconstriction often
occurs in the area, further increasing the
pressure in the blood vessels.
Large emboli (usually those involving
more than 60% of the lung tissue)
affect the cardiovascular system,
causing right-sided heart failure and
decreased ccardiac output (shock).

Sudden death often results in these

cases, which involve greatly increased
resistance in the pulmonary arteries
because of the embolus plus reflex
vasoconstriction due to released
chemical mediators such as serotonin
and histamine. This resistance to the
output from the right ventricle causes
acute cor pulmonale.
Also, there is much less blood returning
from the lungs to the left ventricle and
then to the systemic circulation
(decreased cardiac output).

This can be appreciated by visualizing a

large embolus lying cacross the
bifurcation of the pulmonary artery ( a
“saddle embolus”) and totally blocking
the flow of the blood from the right
ventricle into the lungs.
Pathophysiology
A series of happenings occur inside a patient’s body when he or she has emboli.

• Obstruction. When a thrombus completely or partially obstructs the pulmonary artery or

its branches, the alveolar dead space is increased.

• Impairment. The area receives little to no blood flow and gas exchange is impaired.

• Constriction. Various substances are released from the clot and surrounding area that
cause constriction of the blood vessels and results in pulmonary resistance.
Pathophysiology

• Consequences. Increased pulmonary vascular resistance due to regional

vasoconstriction leading to increase in pulmonary arterial pressure and increased right
ventricle workload are the consequences that follow.

• Failure. When the workload of the right ventricle exceeds the limit, failure may occur.
Signs and Symptoms

• Small emboli – a transient chest pain, cough, or dyspnea may occur. Often unnoticed
but can be significant because it may be a warning of more emboli developing

• Larger emboli – chest pain that increases with coughing or deep breathing, tachypnea,
and dyspnea develop suddenly. Later, hemoptysis and fever are present.

• Hypoxia stimulates a sympathetic response, with anxiety and restlessness, pallor and
tachycardia
Signs and Symptoms

• Massive emboli – cause severe crushing chest pain, low blood pressure, rapid weak
pulse, and loss of consciousness.

• Fat emboli – development of acute respiratory distress, a petechial rash on the trunk,
and neurologic signs such as confusion and disorientation
Diagnostic Test
• Chest X-ray - usually normal but may show infiltrates, atelectasis, elevation of the
diaphragm on the affected side, or a pleural effusion.

• ECG - usually shows sinus tachycardia, PR-interval depression, and nonspecific T-wave
changes.

• ABG analysis - ABG analysis may show hypoxemia and hypocapnia; however, ABG
measurements may be normal even in the presence of PE.

• Pulmonary angiography - allows for direct visualization under fluoroscopy of the arterial
obstruction and accurate assessment of the perfusion deficit.
Diagnostic Test
• duplex venous ultrasound - This test uses radio waves to visualize the flow of blood
and to check for blood clots in your legs.

• Venography - This is a specialized X-ray of the veins of your legs.

• D-dimer test - A type of blood test that is used to help rule out the presence of an
inappropriate blood clot.

• V/Q scan (ventilation/perfusion lung scan) - evaluates the different regions of the
lung and allows comparisons of the percentage of ventilation and perfusion in each
area.
Diagnostic Test

Good to know!

The normal range for D-dimer is 500ng/mL fibrinogen

equivalent units (FEU)

A negative D-dimer result means that it is most likely that

the person tested does not have an acute condition or
disease causing abnormal clot formation or breakdown.

A positive D-dimer result may indicate the presence of an

abnormally high level of fibrin degradation products
 Medical
Management
Because PE is often a medical emergency, emergency
management is of primary concern.

• Anticoagulation therapy. Heparin, and warfarin sodium

has been traditionally been the primary method for
managing acute DVT and PE.

• Thrombolytic therapy. Urokinase, streptokinase, alteplase

are used in treating PE, particularly in patients who are
severely compromised.
 Surgical Removal of the emboli may sometimes need surgical
management.
Management
• Surgical embolectomy. This is the removal of the actual
clot and must be performed by a cardiovascular surgical
team with the patient on cardiopulmonary bypass.

• Transvenous catheter embolectomy. This is a technique

in which a vacuum-cupped catheter is introduced
transvenously into the affected pulmonary artery.

• Interrupting the vena cava. This approach prevents

dislodged thrombi from being swept into the lungs while
allowing adequate blood flow.
Nursing Management
• Prevent venous stasis. Encourage ambulation and
active and passive leg exercises to prevent venous
stasis.

• Manage pain. Turn patient frequently and reposition to

improve ventilation-perfusion ratio.

• Manage oxygen therapy. Assess for signs of

hypoxemia and monitor the pulse oximetry values.

• Relieve anxiety. Encourage the patient to talk about

any fears or concerns related to this frightening
episode.
Nursing Management
• Monitor thrombolytic therapy. Monitoring
thrombolytic and anticoagulant therapy through INR or
PTT.
- INR ( International Normalized Ratio) and PTT
(partial thromboplastin time) are used to monitor
effetiveness of the anticoagulan warfarin.

Normal range of INR is 1 to 2, while for PTT is 30 to 45 seconds.

- Extended PTT times can be a result of anticoagulation
therapy, liver problems, lupus, and other diseases that result in poor
clotting.
Discharge and Home Care Guidelines
• Prevent recurrence. The nurse should instruct the patient about preventing recurrence and reporting
signs and symptoms.

• Adherence. The nurse should monitor the patient’s adherence to the prescribed management plan
and enforces previous instructions.

• Residual effects. The nurse should also monitor for residual effects of the PE and recovery.

• Follow-up checkups. Remind the patient about keeping up with follow-up appointments for
coagulation tests and appointments with the primary care provider.