RISK FACTORS: It is a common disorder associated with trauma, surgical operation including but not limited to; orthopedic, major abdominal, pelvic, and gynecologic surgeries. Among other factors we have pregnancy, Heart Failure, age more than 50 years, hypercoagulable states, and prolonged immobility. It also may occur in apparently healthy people where most thrombi originate in the deep veins of the legs.
CLINICAL MANIFESTATIONS: Symptoms depend on the size of the thrombus and the area of the pulmonary artery occlusion. Dyspnea is the most common symptom. Tachypnea is the most frequent sign. Chest pain is common, usually sudden in onset and pleuritic in nature; it can be substernal and may mimic angina pectoris or a myocardial infarction. Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, syncope, shock, and sudden death may occur. Clinical picture may mimic that of bronchopneumonia or HF. In atypical instances, PE causes few signs and symptoms, whereas in other instances it mimics various other cardiopulmonary disorders.
ASSESSMENT AND DIAGNOSTIC METHODS: Because the symptoms of PE can vary from few to severe, a diagnostic workup is performed to rule out other diseases. The initial diagnostic workup may include chest x-ray, ECG, ABG analysis, and ventilation-perfusion scan. Pulmonary angiography is considered the best method to diagnose PE; however, it may not be feasible, cost-effective, or easily performed, especially with critically ill patients. Spiral CT scan of the lung, D-dimer assay (blood test for evidence of blood clots), and pulmonary arteriogram may be warranted.
PREVENTION: Ambulation or leg exercises in patients on bed rest. Application of sequential compression devices. Anticoagulant therapy for patients whose hemostasis is adequate and who are undergoing major elective abdominal or thoracic surgery.
MEDICAL MANAGEMENT: Immediate objective is to stabilize the cardiopulmonary system. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are inserted to establish routes for medications or fluids that will be needed. A perfusion scan, hemodynamic measurements, and ABG determinations are performed. Spiral (helical) CT or pulmonary angiography may be performed. Hypotension is treated by a slow infusion of dobutamine, which has a dilating effect on the pulmonary vessels and bronchi, or dopamine. The ECG is monitored continuously for dysrhythmias and right ventricular failure, which may occur suddenly. Digitalis glycosides, IV diuretics, and antiarrhythmic agents are administered when appropriate. Blood is drawn for serum electrolytes, complete blood cell count, and hematocrit. If clinical assessment and ABG analysis indicate the need, the patient is intubated and placed on a mechanical ventilator. If the patient has suffered massive embolism and is hypotensive, an indwelling urinary catheter is inserted to monitor urinary output. Small doses of IV morphine or sedatives are administered to relieve patient anxiety, to alleviate chest discomfort, to improve tolerance of the endotracheal tube, and to ease adaptation to the mechanical ventilator.
Anticoagulation Therapy: Anticoagulant therapy (heparin, warfarin sodium [Coumadin]) has traditionally been the primary method for managing acute DVT and PE. Patients must continue to take some form of anticoagulation for at least 3 to 6 months after the embolic event. Major side effects are bleeding anywhere in the body and anaphylactic reaction resulting in shock or death. Other side effects include fever, abnormal liver function, and allergic skin reaction.
Thrombolytic Therapy. Thrombolytic therapy may include urokinase, streptokinase, and alteplase. Bleeding is a significant side effect; nonessential invasive procedures are avoided.
SURGICAL MANAGEMENT: A surgical embolectomy is rarely performed but may be indicated if the patient has a massive PE.
RELATED;
1. ACUTE RESPIRATORY DISTRESS SYNDROME
2. PNEUMONIA
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