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Chapter 20 Pulmonary Embolism and Infarction A B PE C D Figure 20-1. A, Pulmonary embolism (PE). Bronchial smooth muscle constriction (B), atelectasis (C), and alveolar consolidation (D) are common secondary anatomic alterations of the lungs. Slide 1 Copyright © 2006 by Mosby, Inc. Anatomic Alterations of the Lungs Slide 2 Blockage of the pulmonary vascular system Pulmonary infarction Alveolar atelectasis Alveolar consolidation Occasional bronchospasm Copyright © 2006 by Mosby, Inc. Etiology Slide 3 More than 600,000 cases reported yearly in the U.S. From this group, about 30,000 die annually Diagnosis is missed in 70% or more of the cases Thus the possibility of a pulmonary embolism should be considered for any unexplained dyspnea, tachypnea, and chest pain Copyright © 2006 by Mosby, Inc. Etiology Blood clots—most common source of pulmonary emboli Slide 4 Most originate from deep veins in the lower part of the body, i.e., leg veins Other possible causes Fat Air Amniotic fluid Bone marrow Tumor fragments Copyright © 2006 by Mosby, Inc. Etiology Risk factors Slide 5 Venous stasis Prolonged bed rest Prolonged sitting Congestive heart failure Varicose veins Thrombophlebitis Copyright © 2006 by Mosby, Inc. Etiology Risk factors Slide 6 Trauma Bone fractures Extensive injury to soft tissue Postoperative or postpartum states Extensive hip or abdominal operation Phlegmasia alba dolens puerperarum Copyright © 2006 by Mosby, Inc. Etiology Risk factors Slide 7 Hypercoagulation disorders Oral contraceptives Polycythemia Multiple myeloma Others Obesity Malignant neoplasm Pregnancy Burns Copyright © 2006 by Mosby, Inc. Diagnosis and Screening Slide 8 Chest x-ray Electrocardiogram (ECG) . . Ventilation/perfusion scan (V/Q scan) Fast computed tomography scan Pulmonary angiogram Copyright © 2006 by Mosby, Inc. Diagnosis and Screening Additional tests used to detect blood clots in veins Slide 9 Fibrinogen test Extremity venography Duplex ultrasonography (DUS) Magnetic resonance imaging (MRI) Copyright © 2006 by Mosby, Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with PULMONARY EMBOLISM The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with pulmonary embolism (see Figure 20-1). Bronchospasm (see Figure 9-10) also may explain some of the following findings. It occurs rarely and is of little clinical significance compared with the atelectasis and increased physiologic dead space caused by the embolism. Slide 10 Copyright © 2006 by Mosby, Inc. Figure 9-7. Atelectasis clinical scenario. Slide 11 Copyright © 2006 by Mosby, Inc. Figure 9-10. Bronchospasm clinical scenario (e.g., asthma). Slide 12 Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Vital signs Slide 13 Increased respiratory rate Stimulation of the peripheral chemoreceptors Reflexes from the aortic and carotid sinus baroreceptors Increased heart rate Systemic hypotension Copyright © 2006 by Mosby, Inc. Figure 20-2. Dead-space ventilation in pulmonary embolism. Slide 14 Copyright © 2006 by Mosby, Inc. Figure 20-3. Venous admixture develops in pulmonary embolism as a result of bronchial smooth muscle constriction (shuntlike effect). Slide 15 Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Slide 16 Cyanosis Cough and hemoptysis Peripheral edema and venous distention Distended neck veins Swollen and tender liver Chest pain/decreased chest expansion Syncope, lightheadedness, and confusion Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Abnormal heart sounds Increased second heart sound (S2) Increased splitting of the second heart sound (S2) Third heart sound (S3) or ventricular gallop Other cardiac manifestations Slide 17 Right ventricular heave or lift Copyright © 2006 by Mosby, Inc. Figure 20-4. A right ventricular lift can be detected in patients with a pulmonary embolism if significant pulmonary hypertension is present. Slide 18 Copyright © 2006 by Mosby, Inc. Clinical Data Obtained at the Patient’s Bedside Slide 19 Chest assessment findings Crackles Wheezes Pleural friction rub Copyright © 2006 by Mosby, Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures Slide 20 Copyright © 2006 by Mosby, Inc. Arterial Blood Gases Mild to Moderate Pulmonary Embolism Acute alveolar hyperventilation with hypoxemia pH Slide 21 PaCO2 HCO3 (Slightly) PaO2 Copyright © 2006 by Mosby, Inc. Time and Progression of Disease Disease Onset Alveolar Hyperventilation 100 90 PaO2 or PaCO2 80 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 70 60 PaO2 50 40 30 20 10 0 Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation. Slide 22 Copyright © 2006 by Mosby, Inc. Arterial Blood Gases Extensive Pulmonary Embolism and Infarction Acute ventilatory failure with hypoxemia pH Slide 23 PaCO2 HCO3 (Slightly) PaO2 Copyright © 2006 by Mosby, Inc. Time and Progression of Disease Disease Onset Alveolar Hyperventilation Acute Ventilatory Failure 100 90 Pa02 or PaC02 80 70 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Point at which disease becomes severe and patient begins to become fatigued 60 50 40 30 20 10 0 Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure. Slide 24 Copyright © 2006 by Mosby, Inc. Oxygenation Indices QS/QT DO2 VO2 Normal O2ER Slide 25 C(a-v)O2 Normal SvO2 Copyright © 2006 by Mosby, Inc. Hemodynamic Indices (Extensive Pulmonary Embolism) Slide 26 CVP RAP PA PCWP Normal CO SV SVI CI RVSWI LVSWI PVR SVR Normal Copyright © 2006 by Mosby, Inc. Three Major Mechanisms May Contribute to the Pulmonary Hypertension Slide 27 1. Decreased cross-sectional area of the pulmonary vascular system because of the embolus 2. Vasoconstriction induced by humoral agents 3. Vasoconstriction induced by alveolar hypoxia Copyright © 2006 by Mosby, Inc. Abnormal Electrocardiographic Patterns Slide 28 Sinus tachycardia Atrial arrhythmias Atrial tachycardia Atrial flutter Atrial fibrillation Acute right ventricular strain pattern and right bundle branch block P-pulmonale Copyright © 2006 by Mosby, Inc. Radiologic Findings Chest radiograph Slide 29 Increased density Hyperradiolucency distal to the embolus Dilation of the pulmonary arteries Pulmonary edema Right ventricular cardiomegaly Pleural effusion Copyright © 2006 by Mosby, Inc. Figure 20-5. Abnormal ventilation and perfusion lung scans in a patient with a right main pulmonary artery embolism. A, A normal ventilation scan shows a uniform distribution of gas, with the dark areas reflecting the presence of the radioactive gas and, therefore, good ventilation (right lung is on viewer’s left). B, An abnormal perfusion scan. The dark area shown in the right lung represents good blood flow. The white or light areas shown in the left lung represent decreased or completely absent blood flow (right lung is on viewer’s left). Slide 30 Copyright © 2006 by Mosby, Inc. Figure 20-6. Pulmonary emboli. Pulmonary angiogram shows numerous filling defects. Trailing ends of the occluding thromboemboli are particularly well shown (arrows). Slide 31 Copyright © 2006 by Mosby, Inc. General Management of Pulmonary Embolism Fast-acting anticoagulant heparin Calciparine Liquaemin Slow-acting anticoagulant Slide 32 Warfarin • Coumadin • Panwarfin Unfractionated heparin Copyright © 2006 by Mosby, Inc. General Management of Pulmonary Embolism Slide 33 Thrombolytic agents Streptokinase • Kabikinase • Streptase Urokinase • Abbokinase Activase Copyright © 2006 by Mosby, Inc. General Management of Pulmonary Embolism Preventive measures Slide 34 Vein filter Heparin or warfarin therapy Graduated compression stockings Pneumatic compression Copyright © 2006 by Mosby, Inc. General Management of Pulmonary Embolism Respiratory care treatment protocols Slide 35 Oxygen therapy protocol Aerosolized medication protocol Mechanical ventilation protocol Copyright © 2006 by Mosby, Inc. General Management of Pulmonary Embolism Pulmonary embolectomy Slide 36 Last resort Copyright © 2006 by Mosby, Inc. Classroom Discussion Case Study: Pulmonary Embolism Slide 37 Copyright © 2006 by Mosby, Inc.
