pulmonary embolism

PULMONARY EMBOLISM

Bianca Moses Fall 2013

Think back to Willy Wonka’s chocolate river…


Remember Agustus Gloob?



…and when his body clogged the pipe?

Think back to Willy Wonka’s chocolate river…Agustus Gloob



Think back to Willy Wonka’s chocolate river…Agustus Gloob



Giant Pipe

Agustus Gloob

Giant Pipe

This is analogous to a

Agustus Gloob

Giant Pipe

Pulmonary EmbolismThis is analogous to a

Agustus Gloob

Giant Pipe

Pulmonary EmbolismThis is analogous to a PE

Clot from body

Giant Pipe


Clot from body

Pulmonary Artery


Pulmonary Embolism

Simply put, it is a clot that lodged in the arteries of the lungs

Pulmonary Embolism

• Blood Clot


Pulmonary Embolism

• Blood Clot• Broken off part of a tumor


Pulmonary Embolism

• Blood Clot• Broken off part of a tumor• Marrow fat from a broken bone


Pulmonary Embolism

• Blood Clot• Broken off part of a tumor• Marrow fat from a broken bone• Air


Pulmonary Embolism

• Blood Clot• Broken off part of a tumor• Marrow fat from a broken bone• Air• Broken off arterial plaque


Pulmonary Embolism


Pulmonary Embolism


Blood flow may be completely blocked causing sudden death.

Pulmonary Embolism


Blood flow may or partially blocked causing lung damage.

Pulmonary Embolism


Frequently these originate from a DVT

Pulmonary Embolism



Deep Vein Thrombosis

Pulmonary Embolism




So frequently in fact

Pulmonary Embolism




So frequently in fact, they’re commonly both referred to together

Pulmonary Embolism




So frequently in fact, they’re commonly both referred to together… as a VTE

Pulmonary Embolism




So frequently in fact, they’re commonly both referred to together… as a VTE

Venous Thromboembolism


Do you have killer legs?



This was the message in a public

awareness campaign in the

USA to inform about VTE risk

factors






factors

Do you always cross your legs at the knee?






factors


This impedes blood flow





factors


This impedes blood flow

andVenous Thromboembolism



Remaining sedentary for extended periods of time can help a clot form…




Ever heard of travelers thromboembolism?




Ever heard of travelers thromboembolism?

It’s a thing




it’s not as bad as not getting out of bed at all




it’s not as bad as not getting out of bed at all

This is why we, as nurses, encourage early ambulation



Pregnant bellies press on veins in the pelvis slowing blood return from the legs




…anything slowing down blood, is the

perfect





perfect environment for





perfect environment for clot formation





perfect environment for clot formation…as is

Dehydration.

environment for clot formation…as is

Dehydration. It concentrates your platelets…

environment for clot formation…as is

Cancer.

Cancer. Tumors break off and lodge in pulmonary arteries…


As was described in the article:


As was described in the article: Pulmonary embolism caused by spontaneous migration of tumor thrombus of renal cell carcinoma: A report of two cases



Shimada, S., & Saito, H. (2012). Pulmonary embolism caused by spontaneous migration of tumor thrombus of renal cell carcinoma: A report of two cases. International Journal of Urology, 10, 277-278. doi: 10.1111/j.1442-2042.2011.02926.x



An intriguing finding from this piece was that, “Interestingly, tumor emboli do not necessarily develop into pulmonary metastasis.”

Shimada, S., & Saito, H. (2012). Pulmonary embolism caused by spontaneous migration of tumor thrombus of renal cell carcinoma: A report of two cases. International Journal of Urology, 10, 277-278. doi: 10.1111/j.1442-2042.2011.02926.x


and tumors secrete pro-coagulant factors



Welsh, Smith, Yates,

Greenman, Varaveyal and Madden found

that…



Tumors can turn on genes to express tissue factors (TF)



that…






that…

↑TF expression






that…

↑TF expression = ↑ Clots




“Cell-supported coagulation was shown to be cell number dependent,



that…





“Cell-supported coagulation was shown to be cell number dependent, defined by a logarithmic relationship



that…





“Cell-supported coagulation was shown to be cell number dependent, defined by a logarithmic relationship that was consistent across all cell lines”



that…






“Across a range of tumor sites, a consitent relationship is seen between procoagulant potential



that…






“Across a range of tumor sites, a consitent relationship is seen between procoagulant potential and both cell number



that…






“Across a range of tumor sites, a consitent relationship is seen between procoagulant potential and both cell number and TF cell surface expression”



that…




Welsh, J., Smith, J., Yates, K., Greenman, J., Maraveyal, A., & Madden, L. (2012). Tissue factor expression determines tumour cell coagulation kinetics.International Journal of Laboratory Hematology, 34, 396-402. doi: 10.1111/j.1751-553X.2012.01409.x



“Across a range of tumor sites, a consitent relationship is seen between procoagulant potential and both cell number and TF cell surface expression”



that…




With joint replacement surgery

Cancer. Marrow breaks off and lodges in pulmonary arteries…




contributing to a PE



contributing to a PE


Other risk factors include

Venous Valve Malfunction.


Acquired Thrombophilia.



Acquired Thrombophilia. Smoking.




Supplemental Estrogen.

Smoking.



Atria

l Fib

rilla

tion.



Smoking.



Atria

l Fib

rilla

tion.


High Blood Pressure.


Smoking.



Atria

l Fib

rilla

tion.

Venous stasis.




Smoking.



Atria

l Fib

rilla

tion.

Venous stasis.

Genetic Thrombophilia.




Smoking.



Signs and Symptoms of PE


SymptomTriad


Hemoptysis

SymptomTriad


Hemoptysis

Chest Pain

SymptomTriad


Hemoptysis

Chest Pain

• Worse with

SymptomTriad


Hemoptysis

Chest Pain

• Worse with • exertion

SymptomTriad


Hemoptysis

Chest Pain

• Worse with • exertion• deep breathing

SymptomTriad


Hemoptysis

Chest Pain

• Worse with • exertion• deep breathing• bending and stooping

SymptomTriad


Hemoptysis

Chest Pain


• Does not go away with rest

SymptomTriad


Hemoptysis

Chest Pain Dyspnea



SymptomTriad


Hemoptysis

Chest Pain Dyspnea



Sudden and Unexplained

SymptomTriad

Signs and Symptoms of VTE (DVT → PE)


• Wheezing


• Wheezing• Lightheadedness


• Wheezing• Lightheadedness• Low O2 Saturation


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis• Rapid Breathing


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis• Rapid Breathing• Rapid Heartbeat


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis• Rapid Breathing• Rapid Heartbeat• Leg Pain


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis• Rapid Breathing• Rapid Heartbeat• Leg Pain• Leg Discoloration


• Wheezing• Lightheadedness• Low O2 Saturation• Cyanosis• Rapid Breathing• Rapid Heartbeat• Leg Pain• Leg Discoloration• Temperature difference between legs

Wells Prediction Rule

Anticipating • Ruling Out • Detecting



Score of 3+,High DVT Probability



Score of 3+,High DVT Probability Score of 1-2, Moderate Probability



Score of 3+,High DVT Probability Score of 1-2, Moderate Probability Score of ≤0, Low Probability


In a symptomatic patient


In a symptomatic patientdifferentiating betweenright ventricular myocardial infarction


In a symptomatic patientdifferentiating betweenright ventricular myocardial infarctionand pulmonary embolism


In a symptomatic patientdifferentiating betweenright ventricular myocardial infarctionand pulmonary embolismis not a simple task



In an article titled Right Ventricular Myocardial Infarction and Pulmonary

Embolism Differential Diagnosis – a Challenge for the Clinician





Ginghina, C., Caloianu, G., Serban, M., & Dragomir, D. (2010). Right ventricular myocardial infarction and pulmonary embolism differential diagnosis-a challenge for the clinician


Dr.Ginghina finds that an exhaustive diagnostic regimen is necessary to definitively rule out, or rule in the condition responsible for PE-like symptoms





Dr.Ginghina finds that an exhaustive diagnostic regimen is necessary to definitively rule out, or rule in the condition responsible for PE-like symptoms

A regimen comparable to these tests that follow


• Chest X-Rays


• Chest X-Rays• Rule’s out conditions that mimic PE



• Blood tests



• Blood tests• Full CBC



• Blood tests• Full CBC• Erythrocyte Sed. Rate



• Blood tests• Full CBC• Erythrocyte Sed. Rate• Renal Function Tests



• Blood tests• Full CBC• Erythrocyte Sed. Rate• Renal Function Tests• Liver Enzymes Panel



• Blood tests• Full CBC• Erythrocyte Sed. Rate• Renal Function Tests• Liver Enzymes Panel• Electrolyte Screen



• Blood tests• Full CBC• Erythrocyte Sed. Rate• Renal Function Tests• Liver Enzymes Panel• Electrolyte Screen• Blood gases




• ECG




• ECG • D-Dimer test





Sensitive





Sensitive, but not specific






If Positive






Clot = yes






Clot = yesLocation = unknown

Ventilation-Perfusion Scan




Inhale Radioactive material



Inhale Radioactive material and trace where it goes



Inhale Radioactive material and trace where it goes and more importantly,



Inhale Radioactive material and trace where it goes and more importantly, where it doesn’t




Look for the same patterns




Look for the same patterns

when radioactive material is

injected

Spiral CT with contrast


Pulmonary Angiogram


Echocardiogram


Echocardiogram


Right ventricular dilation

Echocardiogram



Leftward shift of the

Echocardiogram



Leftward shift of the

inter-ventricular septum

MRI


Drug Interventions

• Anticoagulants to prevent new clots

Drug Interventions

• Anticoagulants to prevent new clots• Includes

Drug Interventions

• Anticoagulants to prevent new clots• Includes• Warfarin (Coumadin)• Rivaroxaban (Xarelto)• Low Molecular Weight Heparin• and others…

Drug Interventions


• Takes a few days for full effect

Drug Interventions


• Takes a few days for full effect• Easy bleeding and bruising

Drug Interventions


• Takes a few days for full effect• Easy bleeding and bruising• No razors• Soft bristle tooth-brushes

Drug Interventions

• Thrombolytics

Drug Interventions

• Thrombolytics• Includes

Drug Interventions

• Thrombolytics• Includes• Alteplase• Reteplase• Tenecteplase• and others ending in -plase…

Drug Interventions


• Should be administered within 60 minutes of thrombotic event

Drug Interventions



• Can cause sudden and severe bleeding

Drug Interventions



• Can cause sudden and severe bleeding• Use only in emergency situations

Invasive Interventions

• Catheter Embolectomy


• Catheter Embolectomy• Uses a catheter to suction the clot out



• Surgical Embolectomy



• Surgical Embolectomy• Emergency surgery to remove as many blood clots

as possible




as possible• Typically used for large clots in central pulmonary

artery





artery• Vein Filter





artery• Vein Filter• Wire mesh device positioned in inferior vena cava





artery• Vein Filter• Wire mesh device positioned in inferior vena cava• Catches clots before they reach the lungs





artery• Vein Filter• Wire mesh device positioned in inferior vena cava• Catches clots before they reach the lungs• Reserved for when medication isn’t indicated

Nursing Considerations

In the journal Nursing Standard, Farley et al describes the nursing considerations for PE as follows:



Farley, A., McLafferty, E., & Hendry, C. (2009). Pulmonary embolism: identification, clinical features and management. Nursing Standard, 23(28), 49-56.




Assess the risk of VTE using Virchow’s triad:




Assess the risk of VTE using Virchow’s triad: Hypercoagulability





Venous stasis

Hypercoagulability





Venous stasis

HypercoagulabilityVeno

us tra

uma




Encourage early mobilization




Encourage early mobilization

If they can’t walk, have them perform foot/leg exercises in bed




Compression




Compression• SCD




Compression• SCD• TED Hose




Compression• SCD• TED Hose• Knee length• Thigh length




Administer Anticoagulants




Administer Anticoagulants • Assess regularly for occult or overt bleeding




Administer Anticoagulants • Assess regularly for occult or overt bleeding

• Bleeding gums• Nosebleeds• Black and tarry stools• Hematuria• Drops in BP




Administer Anticoagulants • Warfarin Therapy





• Encourage pt to maintain a regular intake of vitamin K (ie.leafy greens)





• Encourage pt to maintain a regular intake of vitamin K (ie.leafy greens)

• Advise patient to not take any medications containing aspirin or NSAIDS




Oxygen Therapy




Oxygen Therapy• Administer to every pt suspected of PE




Oxygen Therapy• Administer to every pt suspected of PE• Increased O2 promotes pulmonary

vascular dilatation




Patient Education




Patient Education• Remain Hydrated• Trio of symptoms• Avoid constrictive clothing• Exercise calf muscles frequently• Wear compression stockings for long hauls


Patient Education


Patient Education• Walk at least once an hour when sitting


Patient Education• Walk at least once an hour when sitting• Lose weight


Patient Education• Walk at least once an hour when sitting• Lose weight• Stop smoking


Patient Education• Walk at least once an hour when sitting• Lose weight• Stop smoking• Instate safety measure to avoid injury while on

anticoagulants


Patient Education• Walk at least once an hour when sitting• Lose weight• Stop smoking• Instate safety measure to avoid injury while on

anticoagulants• For patients with risk factors for atherosclerosis

and are concerned about PE, consider a vegan or vegetarian diet


Patient Education

• For patients with risk factors for atherosclerosis and are concerned about PE, consider a vegan or vegetarian diet


Patient Education


A study by the Cleveland Clinic explored the health benefits of a

vegan or vegetarian diet


Patient Education



vegan or vegetarian dietThey found that


Patient Education




Red Meat = ↑↑↑ in Carnitine


Patient Education




Red Meat = ↑↑↑ in Carnitine &


Patient Education





Carnitine


Patient Education




Carnitine



Patient Education




Carnitine

Human Digestive

Tract



Patient Education




Carnitine

Human Digestive

Tract

Gut microbes do a conversion



Patient Education




Carnitine

Human Digestive

Tract

TMAO




Patient Education




Carnitine

Human Digestive

Tract

TMAO =Promotes atherosclerosis in humans




Patient Education A study by the Cleveland Clinic explored the health benefits of a


Carnitine Carnitine





Carnitine

Carnivore Digestive

Tract

Carnitine





Carnitine

Carnivore Digestive

Tract

Carnitine

Vegan Digestive

Tract





Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract







Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO







Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO




↑↑↑ Carnitine




Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO




↑↑↑ Carnitine

Vegan Digestive

Tract




Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO




↑↑↑ Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO




Carnitine

Carnivore Digestive

Tract

↑↑↑ TMAO

Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO




↑↑↑ Carnitine

Vegan Digestive

Tract

↓↓↓ TMAO

Less atherosclerosis = Less chance of PE

References

Adam, S. S., McDuffie, J. R., Lachiewicz, P. F., Ortel, T. L., & Williams Jr., J. W. (2013). Comparative Effectiveness of New Oral Anticoagulants and Standard Thromboprophylaxis in Patients Having Total Hip or Knee Replacement. Annals Of Internal Medicine, 159(4), 275-284.

Ambro, L. (2013, April 07). Cleveland clinic researchers discover new link between heart disease and red meat. Cleveland Clinic News Service, Retrieved from http://www.eurekalert.org/pub_releases/2013-04/cc-ccr040513.php

Dhamanaskar, K. P., Figueira, K. E., Jerome, S. C., & Yemen, B. L. (2013). Test Bolus Technique for Detection of Pulmonary Emboli at 64-Slice Multidetector Computed Tomography Angiography. Canadian Association Of Radiologists Journal, 64(3), 226-228. doi:10.1016/j.carj.2012.05.001



Headley, C. M., & Melander, S. (2011). When It May Be a Pulmonary Embolism. Nephrology Nursing Journal, 38(2), 127-152.

Husted, H., Otte, K., Kristensen, B., Ørsnes, T., Wong, C., & Kehlet, H. (2010). Low risk of thromboembolic complications after fast-track hip and knee arthroplasty. Acta Orthopaedica, 81(5), 599-605. doi:10.3109/17453674.2010.525196

Meetoo, D. (2013). Understanding and managing deep vein thrombosis. Nurse Prescribing, 11(8), 390-395.

(n.d.). Retrieved from nydailynews.com/entertainment/tv-movies/willy-wonka-chocolate-factory-gallery-1.52509?pmSlide=4

(n.d.). Retrieved from mpoullis.com/thorcd/pangio/PAGE10.HTM#Normal

(n.d.). Retrieved from stanfordhospital.org/newsEvents/newsReleases/2010/ivc-filter-removal-laser.html

(n.d.). Retrieved from hindustanlifecare.com/ted.htm

(n.d.). Retrieved from lifeofaphysiostudent.wordpress.com/category/cardiopulmonary/

(n.d.). Retrieved from ipixler.com/view/pulmonary-embolism_8/

(n.d.). Retrieved from bing.com/images/search?q=pulmonary+embolism&FORM=HDRSC2&id=D157EA213C5146A3A434883172749DD990F47D8A&selectedIndex=130#view=detail&id=D157EA213C5146A3A434883172749DD990F47D8A&selectedIndex=0

(n.d.). Retrieved from bing.com/images/search?q=chest+x-ray+tumor&go=&qs=n&form=QBIR&pq=chest+x-ray+tumor&sc=8-14&sp=-1&sk=#view=detail&id=6F7389AFAAC5690A91D4169B03AE06E5E78C1DDA&selectedIndex=23

(n.d.). Retrieved from blog.lib.umn.edu/kille001/labmedpathol6290/RainbowTubes2.jpg

(n.d.). Retrieved from cardiophile.org/2009/11/ecg-in-left-main-coronary-artery-stenosis/

(n.d.). Retrieved from avicennajmed.com/viewimage.asp?img=AvicennaJMed_2011_1_2_58_90918_u6.jpg

(n.d.). Retrieved from e-radiography.net/radpath/p/pe.htm

(n.d.). Retrieved from medandlife.ro/medandlife431.html

(n.d.). Retrieved from abdominalaneurysm.net/mri-of-pulmonary-artery-detection-of-pulmonary-embolism/

Ostwanj, W., & Arabj, M. (2011). Alteration in pulmonary perfusion due to iatrogenic pulmonary vein stenosis: A mimicker of pulmonary embolism. Avicenna Journal of Medicine, 1, 58-60.

Perry, M. (2008). Knowing the early signs of pulmonary embolism. Practice Nursing, 19(12), 620-623

Smithburger, P. L., Campbell, S., & Kane-Gill, S. L. (2013). Alteplase Treatment of Acute Pulmonary Embolism in the Intensive Care Unit. Critical Care Nurse, 33(2), 17-27. doi:10.4037/ccn2013626

WELSH, J. J., SMITH, J. D., YATES, K. R., GREENMAN, J. J., MARAVEYAS, A. A., & MADDEN, L. A. (2012). Tissue factor expression determines tumour cell coagulation kinetics. International Journal Of Laboratory Hematology, 34(4), 396-402. doi:10.1111/j.1751-553X.2012.01409.x

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