drsujnanendra's DOCTORSDOC: Pulmonary Embolism

Wednesday, May 27, 2026

Pulmonary Embolism

&nbs Pulmonary Embolism - Clinical Infographic

⚡ 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

Well's Score → Pre-test probability assessment

D-dimer → If low/intermediate probability (⚠️ NOT useful in hospitalized/postop patients)

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

🚨 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).