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Pulmonary embolus

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AETIOLOGY AND RISK FACTORS - An embolus is a foreign substance (such as fat, air, bone marrow, amniotic fluid, tumour tissue or, more commonly, a thrombus) that is carried through the bloodstream.


VOL: 99, ISSUE: 15, PAGE NO: 30

AETIOLOGY AND RISK FACTORS - An embolus is a foreign substance (such as fat, air, bone marrow, amniotic fluid, tumour tissue or, more commonly, a thrombus) that is carried through the bloodstream.
- Pulmonary embolus (PE) is commonly caused by a blood clot derived from deep vein thrombosis (DVT) of one of the leg veins.

- Clots may break off from a larger clot in one of the deep veins and travel with venous blood to the right side of the heart. There they are pumped into a pulmonary vessel resulting in a part of the vessel being occluded.

- If a large pulmonary vessel is obstructed then alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may occur.

- Risk factors for pulmonary embolus include: age (it is more common in people over 40); obesity; taking hormone replacement therapy or the Pill; altered blood constituents with increased coagulation; damaged blood vessel walls; stagnation/ immobilisation, particularly associated with childbirth, congestive heart failure or surgery; long-haul air travel; and a family history of or previous experience of PE or DVT.

- Sudden chest pain.

- Shock.

- Cyanosis.

COMPLICATIONS - Pulmonary infarction, which often occurs within 24 hours of the formation of a PE. This is further characterised by pleural effusion, haemoptysis, fever, tachycardia, leucocytosis, atrial arrhythmias and striking distension of the neck veins. The effect of the infarct depends on the size of the vessel occluded.
- Large thrombi can be devastating, causing sudden death in 50 per cent of patients with PE.

INVESTIGATIONS - Medical history and a full physical examination.
- Arterial blood gas analysis.

- Electrocardiogram.

- Lung scan.

- Pulmonary angiogram.

- Spiral computerised tomography (CT) scan.

- PE can be difficult to distinguish from myocardial infarction and pneumonia.

TREATMENT - Anticoagulation therapy (such as heparin) to prevent the development of new thrombi.
- Oral anticoagulation therapy (warfarin) for up to six months.

- Oxygen therapy to manage hypoxaemia (depleted oxygen in arterial blood). Also endotracheal intubation and artificial ventilation.

- Intravenous opiates (morphine sulphate) to relieve pain.

- Surgical intervention: embolectomy (surgical removal of the embolus).

NURSING IMPLICATIONS - Nurses should be aware of the predisposing factors of DVT and of preventive measures such as subcutaneous heparin, compression stockings, mobilisation and good fluid intake.
- Close monitoring of cardiopulmonary function.

- Alleviation of patient anxiety, often due to respiratory distress.

- Awareness of risk of bleeding as a result of anticoagulant therapy and patient education of risk factors.

RESEARCH AND DEVELOPMENT - See the British Medical Journal’s Clinical Evidence website, Pubmed and OMNI for summary findings.


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