pulmonary embolism

Pulmonary Embolism 

Definition

Pulmonary embolism is an obstruction of a blood vessel in the lungs, usually due to a blood clot, which blocks a coronary artery.

Description

Pulmonary embolism is a fairly common condition that can be fatal. According to the American Heart Association, an estimated 600,000 Americans develop pulmonary embolism annually; 60,000 die from it. As many as 25,000 Americans are hospitalized each year for pulmonary embolism, which is a relatively common complication in hospitalized patients. Even without warning symptoms, pulmonary embolism can cause sudden death. Treatment is not always successful.

Pulmonary embolism is difficult to diagnose. Less than 10% of patients who die from pulmonary embolism were diagnosed with the condition. It occurs when emboli block a pulmonary artery, usually due to a blood clot that breaks off from a large vein and travels to the lungs. More than 90% of cases of pulmonary embolism are complications of deep vein thrombosis, blood clots from the leg or pelvic veins. Emboli can also be comprised of fat, air, or tumor tissue. When emboli block the main pulmonary artery, pulmonary embolism can quickly become fatal.

Causes and symptoms

Pulmonary embolism is caused by emboli that travel through the blood stream to the lungs and block a pulmonary artery. When this occurs, circulation and oxygenation of blood is compromised. The emboli are usually formed from blood clots but are occasionally comprised of air, fat, or tumor tissue. Risk factors include: prolonged bed rest, surgery, childbirth, heart attack, stroke, congestive heart failure, cancer, obesity, a broken hip or leg, oral contraceptives, sickle cell anemia, congenital coagulation disorders, chest trauma, certain congenital heart defects, and old age.

Common symptoms of pulmonary embolism include:

• labored breathing, sometimes accompanied by chest pain.
• a rapid pulse.
• a cough that produces bloody sputum.
• a low fever.
• fluid build-up in the lungs.

Less common symptoms include:

• coughing up a lot of blood
• pain caused by movement
• leg swelling
• bluish skin
• fainting
• swollen neck veins

In some cases there are no symptoms.

Diagnosis

Pulmonary embolism can be diagnosed through the patient's history, a physical exam, and diagnostic tests including chest x ray, lung scan, pulmonary angiography, electrocardiography, arterial blood gas measurements, and leg vein ultrasonography or venography.

A chest x ray can be normal or show fluid or other signs and rule out other diseases. The lung scan shows poor flow of blood in areas beyond blocked arteries. The patient inhales a small amount of radiopharmaceutical and pictures of airflow into the lungs are taken with a gamma camera. Then a different radiopharmaceutical is injected into an arm vein and lung blood flow is scanned. A normal result essentially rules out pulmonary embolism. A lung scan can be performed in a hospital or an outpatient facility and takes about 45 minutes.

Pulmonary angiography is the most reliable test for diagnosing pulmonary embolism but it is not used often, because it carries some risk and is expensive, invasive, and not readily available in many hospitals. Pulmonary angiography is a radiographic test which involves injection of a pharmaceutical "contrast agent" to show up the pulmonary arteries. A cinematic camera records the blood flow through the lungs of the patient, who lies on a table. Pulmonary angiography is usually performed in a hospital's radiology department and takes 30 minutes to one hour.

An electrocardiograph shows the heart's electrical activity and helps distinguish pulmonary embolism from a heart attack. Electrodes covered with conducting jelly are placed on the patient's chest, arms, and legs. Impulses of the heart's activity are traced on paper. The test takes about 10 minutes and can be performed in a physician's office or hospital lab.

Arterial blood gas measurements can be helpful, but they are rarely diagnostic for pulmonary embolism. Blood is taken from an artery instead of a vein, usually in the wrist and it is analyzed for oxygen, carbon dioxide and acid levels.

Venography is used to look for the most likely source of pulmonary embolism, deep vein thrombosis. It is very accurate, but it is not used often, because it is painful, expensive, exposes the patient to a fairly high dose of radiation, and can cause complications. Venography identifies the location, extent, and degree of attachment of the blood clots and enables the condition of the deep leg veins to be assessed. A contrast solution is injected into a foot vein through a catheter. The physician observes the movement of the solution through the vein with a fluoroscope while a series of x rays are taken. Venography takes between 30-45 minutes and can be done in a physician's office, a laboratory, or a hospital. Radionuclide venography, in which a radioactive isotope is injected, is occasionally used, especially if a patient has had reactions to contrast solutions. Most commonly performed are ultrasound and Doppler studies of leg veins.

Treatment

Patients with pulmonary embolism are hospitalized and generally treated with clot-dissolving and clot-preventing drugs. Oxygen therapy is often needed to maintain normal oxygen concentrations. For people who can't take anticoagulants and in some other cases, surgery may be needed to insert a device that filters blood returning to the heart and lungs. The goal of treatment is to maintain the patient's cardiovascular and respiratory functions while the blockage resolves, which takes 10-14 days, and to prevent the formation of other emboli.

Thrombolytic therapy to dissolve blood clots is the aggressive treatment for very severe pulmonary embolism. Streptokinase, urokinase, and recombinant tissue plasminogen activator (TPA) are thrombolytic agents. Heparin is the injectable anticoagulant (clotpreventing) drug of choice for preventing formation of blood clots. Warfarin, an oral anticoagulant, is usually continued when the patient leaves the hospital and doesn't need heparin any longer.

Key terms

Deep vein thrombosis — A blood clot in the calf's deep vein. This frequently leads to pulmonary embolism if untreated.

Emboli — Clots or other substances that travel through the blood stream and get stuck in an artery, blocking circulation.

Thrombosis — The development of a blood clot inside a blood vessel.

Prognosis

About 10% of patients with pulmonary embolism die suddenly within the first hour of onset of the condition. The outcome for all other patients is generally good; only 3% of patients who are properly diagnosed and treated die. In cases of undiagnosed pulmonary embolism, about 30% of patients die.

Prevention

Pulmonary embolism risk can be reduced in certain patients through judicious use of antithrombotic drugs such as heparin, venous interruption, gradient elastic stockings and/or intermittent pneumatic compression of the legs.

Resources

Organizations

American Heart Association. 7320 Greenville Ave. Dallas, TX 75231. (214) 373-6300 or (800) 242-8721. inquire@heart.org http://www.americanheart.org.

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embolism /em·bo·lism/ (em´bŏ-lizm) the sudden blocking of an artery by a clot or foreign material which has been brought to its site of lodgment by the blood current.

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air embolism  that due to air bubbles entering the veins from trauma, surgical procedures, or severe decompression sickness.

cerebral embolism  embolism of a cerebral artery.

coronary embolism  embolism of a coronary artery.

fat embolism  obstruction by a fat embolus, occurring especially after fractures of large bones.

miliary embolism  embolism affecting many small blood vessels.

paradoxical embolism  blockage of a systemic artery by a thrombus originating in a systemic vein that has passed through a defect in the interatrial or interventricular septum.

pulmonary embolism  obstruction of the pulmonary artery or one of its branches by an embolus.

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pulmonary embolism

n. Abbr. PE

The obstruction of pulmonary arteries, usually by detached fragments of a clot from a leg or pelvic vein.

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pulmonary embolism (PE),

the blockage of a pulmonary artery by fat, air, tumor tissue, or a thrombus that usually arises from a peripheral vein (most frequently one of the deep veins of the legs). Predisposing factors include an alteration of blood constituents with increased coagulation, damage to blood vessel walls, and stagnation or immobilization, especially when associated with pregnancy and childbirth, congestive heart failure, polycythemia, or surgery. Pulmonary embolism is difficult to distinguish from myocardial infarction and pneumonia. It is characterized by dyspnea, anxiety, sudden chest pain, shock, and cyanosis. Pulmonary infarction, which often occurs within 24 hours after the formation of a pulmonary embolus, is further characterized by pleural effusion, hemoptysis, leukocytosis, fever, tachycardia, atrial arrhythmias, and striking distension of the neck veins. Analysis of blood gases reveals arterial hypoxia and hypocapnia. Pulmonary embolism is detected by chest radiographic films, pulmonary angiography, and radioscanning of the lung fields. Two thirds of patients with a massive pulmonary embolus die within 2 hours. Initial resuscitative measures include external cardiac massage, oxygen, vasopressor drugs, embolectomy, and correction of acidosis. The formation of further emboli is prevented by the use of anticoagulants, sometimes the use of streptokinase or urokinase, and also surgical intervention. Ambulation, exercise, and use of sequential compression devices on the lower extremities also are recommended for prevention. A vena cava filter may be inserted if pulmonary emboli recur.

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pulmonary embolism,

n the obstruction of a pulmonary artery due to the presence of air, fat, blood clot, or a tumor. In general, the obstruction originates from a peripheral vein, which is most frequently located in the legs. Symptoms such as labored breathing, shock, chest pain, and cyanosis appear and are similar to those of pneumonia or a myocardial infarction. Also called
PE.

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pulmonary embolism, (em´bliz´m),

n the blockage of a pulmonary artery by foreign matter such as fat, air, tumor tissue, or a thrombus that usually arises from a peripheral vein. It is difficult to distinguish from myocardial infarction and pneumonia.

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pulmonary embolism

Pulmonary embolus, pulmonary thromboembolism Internal medicine The migration of an embolus of material, often a blood clot, from elsewhere in circulation, lodging in the pulmonary arteries, occluding same and causing pulmonary infarction, right heart failure, and ↓ oxygenation; most–± 95% originate in the deep–popliteal, femoral, iliac leg veins; PE causes ± 4% of all US hospital deaths/yr–50,000, and is largely preventable Clinical Dyspnea, chest pain, tachycardia, tachypnea, low-grade fever, ± hemoptysis, syncope, ± signs of DVT–eg, right ventricular heave, right-sided S3, rales; PE is underdiagnosed as the classic signs of
dyspnea–seen in 59%, chest pain–17%, and hemoptysis–3% are absent, or the Pt may be unable to communicate as he/she is comatose or sedated Imaging–CXR Usually normal, rarely Hampton sign–wedge shaped infarct or Westermark sign–low blood in embolic lung zone; VQ scan Lung mismatch Pulmonary angiogram Accurate but a high-risk procedure in these Pts Ultrasound DVT may be seen EKG Sinus tachycardia, nonspecific ST-T wave changes–pathognomonic SI, QIII, TIII ABG Respiratory alkalosis– ↑ pH, ↓ CO₂ < 80 mm Hg Risk factors Blood stasis, immobilization, CHF, surgery, trauma, venous endothelial damage, hypercoagulability–eg, pregnancy, post-partum, oral contraceptives, protein C deficiency, protein S deficiency, factor V–Leiden mutation, malignancy, severe burns Prevention Early post-surgical and postpartum ambulation, or exercise if Pt is bed-ridden, anticoagulation, inferior vena caval filters Management Heparinization; long-term anticoagulation with warfarin

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Patient discussion about pulmonary embolism.

Q. What is the differential diagnosis of chest pain in a 35 year old woman? I am a 35 years old woman. I suffer from chest pain for about 24 hours. I just came back from a trip to Europe, and i feel really bad. I smoke and I take anti contraceptive and i know that I am at a risk for pulmonary embolism or costochondritis. Cat it be something else?

A. The differential diagnosis of chest pain is very wide.
It can start in costochondritis if u carried a lot of luggage or might be pulmonary embolism if you didn't move from the chair all the flight. But it can also be a sign for an acute coronary syndrome (even at the age of 35) or a pericarditis. To be sure you need to consult with your GP.

Q. Does anyone have any experience or suggestions regarding aerobic exercise post DVT and/or PE?

A. drink a lot of water and be aware. if you take your meds i think there shouldn't be a problem, but i strongly recommend asking your physician about it. he knows you and the problem and can give you a much much better answer.