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🫁 PULMONARY EMBOLISM (PE)
A Clot That Blocks Blood Flow to the Lungs
⚡ Virchow's Thrombotic Triad
Venous Stasis
- Prolonged bed rest
- Immobilization
- Prolonged sitting
- Heart failure
Endothelial Injury
- Trauma/fractures
- Surgery
- Central lines
- Vasculitis
Hypercoagulability
- Cancer
- Pregnancy
- OCPs/HRT
- Factor V Leiden
🎯 High-Risk Conditions
- Recent surgery (hip/knee)
- Active cancer
- Long-haul travel/flights
- Pregnancy/postpartum
- Central venous lines
- Obesity
- Prior DVT/PE
- COVID-19
⚠️ Signs & Symptoms
- Sudden dyspnea (most common)
- Chest pain (pleuritic)
- Unexplained tachycardia (HR >100)
- Hypoxia
- Syncope/near syncope
- Apprehension/sense of doom
- Leg swelling/pain (DVT)
- Hemoptysis
🔍 Diagnostic Workup
Order of Priority
1
Well's Score → Pre-test probability assessment
2
D-dimer → If low/intermediate probability (⚠️ NOT useful in hospitalized/postop patients)
3
CTPA → GOLD STANDARD (filling defect in pulmonary artery)
📋 Well's Score for PE (Simplified)
| Clinical Feature | Points |
|---|---|
| Clinical signs/symptoms of DVT | +3 |
| PE is #1 diagnosis OR equally likely | +3 |
| Heart rate > 100 bpm | +1.5 |
| Immobilization ≥3 days OR surgery in past 4 weeks | +1.5 |
| Prior DVT/PE | +1.5 |
| Hemoptysis | +1 |
| Malignancy (active/treatment within 6 months) | +1 |
Interpretation:
≤4 points = PE unlikely → order D-dimer
>4 points = PE likely → proceed to CTPA
≤4 points = PE unlikely → order D-dimer
>4 points = PE likely → proceed to CTPA
🚨 MASSIVE PE RED FLAGS
- Systolic BP < 90 mmHg
- Respiratory arrest or agonal breathing
- Pulseless electrical activity (PEA)
- Altered mental status + hypotension
- Cardiogenic shock
- Classic triad: Syncope + Tachycardia + Hypoxia (found in only 20%)
⏰ Time is lung. Time is life. Call Rapid Response / Code IMMEDIATELY
👨⚕️ Immediate Nursing Actions
1️⃣ ASSESS & STABILIZE
- ABCs assessment
- High-flow oxygen (target SpO₂ ≥92%)
- Two large-bore IV access
- Continuous cardiac monitoring
- Bedrest (avoid Valsalva, sudden movement)
2️⃣ PREPARE FOR THERAPY
- Anticoagulation: Heparin (UFH/LMWH)
- ⚠️ Do NOT delay for CTPA
- Thrombolytics (massive PE only): tPA
- Vasopressors if hypotensive
3️⃣ MONITOR COMPLICATIONS
- Bleeding signs (especially on thrombolytics)
- Right heart failure (JVD, edema)
- Recurrent PE symptoms
- Hemodynamic status
4️⃣ CALL FOR HELP
- Rapid Response if unstable
- Code Blue if massive PE
- Consider thrombectomy/embolectomy
- PERT Team consultation
💊 Treatment Quick Reference
| PE Severity | Treatment | Anticoagulation Duration |
|---|---|---|
| Low-risk (hemodynamically stable) |
LMWH / DOAC (Apixaban, Rivaroxaban) |
3–6 months |
| Intermediate-risk (RV strain on echo/troponin+) |
LMWH → DOAC or Warfarin | 3–12 months |
| High-risk/Massive (hypotensive) |
Thrombolysis (tPA) + Anticoagulation |
Minimum 3 months |
| Contraindication to Anticoag | IVC filter (removable) | Until filter removed |
💡 Key Nursing Pearls
- "PE can mimic many things" – Anxiety, pneumonia, COPD, MI, pericarditis
- Syncope + tachycardia + hypoxia → Massive PE until proven otherwise
- Do NOT delay anticoagulation while waiting for CTPA if high clinical suspicion
- D-dimer is NOT useful in hospitalized/postop patients (always elevated)
- Pregnant patients → V/Q scan or CTPA (fetal radiation risk low after 1st trimester)
- Low-risk PE → May be discharged on DOACs (if home safe, no hypoxia, no RV strain)
📚 Patient Education & Discharge
💊 Medication Adherence
Anticoagulants are NOT optional. Missing doses risks recurrent PE. Take medications exactly as prescribed.
🩸 Bleeding Precautions
Report black/tarry stools, blood in urine, large bruises, headache, or vomiting immediately.
🚶 Activity & Movement
Gradual return to activity. Avoid prolonged sitting. Walk hourly. Compression stockings reduce post-thrombotic syndrome.
⚠️ Signs of Recurrence
New dyspnea, chest pain, syncope → Go to ER immediately.
✈️ Travel Safety
Stay mobile, hydrate well, aisle seat. Consider LMWH before long flights (high-risk patients).
🧦 Compression Stockings
20–30 mmHg compression reduces post-thrombotic syndrome risk (swelling, pain).
