Pulmonary Embolism can be fatal depending on how big the emboli that migrated to the lungs via the pulmonary artery. Tha source of this clot may come from a DVT of the lower extremity that came off free and travelled via femoral to the inferior vena cava. Because of the volume of blood that comes from SVC and IVC, blood continue to be pumped from the RA to the RV via the TV. Now, clot can easily be trapped in the smaller calliber branch of the pulmonary artery that supplies the left and right lung. Symptom manifestation depends on the degree of obstruction.
Signs and Symptoms:
1. SHOB and difficulty of breathing- usually shallow because of pain with deep breathing
2. Chest pain- pleuretic in nature meaning pain with inspiration
3. Tachypnea- is a compensatory mechanism to increase oxygenation
4. TACHYCARDIA- is also a compensatory mechanism to increase cardiac output and as manifestation of anxiety and fear. 8-69% of cases.
EKG changes is seen in 20% of cases—- Large S wave in L 1; large Q wave and T wave inversion in L 111; Right axis deviation and RBBB. This changes are manifestation of right heart strain or cor pulmonale.
5. Cyanosis- lips and finger tips- as a result of hypoxemia
6. Hemoptysis- coughing out of blood
1. CT pulmonary Angio- the gold standard of diagnosing PE
2. D- Dimer- a blood testing the presence of a small protein fragment released after a blood clot degraded by fibrinolysis called Fibrin Degradation Product.It contains two crosslinke D fragments of the the fibrinogen protein thus deriving the name D- Dimer.
3. V/Q scan- a ventilation/perfusion scan- this exam will show areas of the lung that are ventilated but not perfused.
4. EKG- right heart strain
5. Echocardiogram- will diagnose right heart dysfunction which means that the pulmonary artery is severely obstructed and the heart is unable to match the pressure.
************failure to immediately treat to dissolve the clot/ or remove will result to the ff. complications and eventually death.
************* severe Right ventricle dilatation as a result of increased pressure and blood not moving forward to the lung circulation.
************* Increased BNP and Troponin secondary to right heart strain………
1. anticoagulation- is the first line and mainstay of treatment. The purpose is to prevent further clot formation.
a. Heparin- hospitalized pt’s are usually started on Heparin to prevent further clot formation. Although heparin does not desolve the clot, it allows the body’s natural clot lysis mechanism to breakdown the clot normally. It is also used to bridge anticoagulation when initiating warfarin until INR is therapeutic.
b. Warfarin- ideal INR for PE is 2-3.Patient are usaully advised to take warfarin for 3- 6 months. In cases of recurrent PE and DVT, Warfarin is taken lifelong.
2. Thrombolysis – its main purpose is to immediately dissolve the clot and reestablish perfusion and blood flow. This is indicated in the presence of Massive PE with evidence of hemodynamic instability; shock/hypotension
3. Pulmonary Thrombectomy- surgical removal of clot was uncommon due to its poor long term outcome but surgical revisions and approach seem to benefit certain populations.
****************** chonic PE can lead to pulmonary hypertension and is treated with pulmonary endarterectomy.
4. Inferior Vena Cava Filter- IVC filter implant purpose is to prevent further clot migration to the heart and lung. When anticoagulation is contraindicated due to bleeding or is ineffective.