PULMONARY EMBOLISM

Recognition

Definition

• “Pulmonary Embolism is a condition in which one or more emboli, usually arising from a thrombus formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing sever respiratory dysfunction” (NICE CKS Pulmonary Embolism).

Risk Factors

• Strong
  • Fracture of lower limb
  • Hospitalisation for heart failure or atrial fibrillation
  • Hip or knee replacement
  • Major Trauma
  • Myocardial infarction
  • Previous deep vein thrombosis (DVT) or pulmonary embolus (PE)
  • Spinal cord injury
• Other
  • Malignancy
  • Post-surgery
  • Immobility
  • Oral contraceptive pill
  • Pregnancy
  • Increasing age
  • Obesity
  • Infection
  • Inherited disorders e.g. thrombophilia

History

If possible, ascertain if patient has:

• Previous diagnosis of PE or DVT
• Diagnosis of:
  • Cancer
• History of:
  • Long haul flight
  • Operation
  • Trauma
  • Immobilisation
• Family history of inherited blood clotting disorder

General symptoms

• Sudden onset of Shortness of breath (dyspnoea)
• Cyanosis
• Pleuritic chest pain
• Haemoptysis
• Syncope
• Leg pain, swelling and erythema

General Signs

• Tachypnoeic
• Low oxygen saturations
• Tachycardia
• Hypotensive
• Raised Jugular venous pressure
• Fever

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (Ohours) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
  • Usually nothing abnormal detected
  • Pleural friction rub may be present
• Arterial blood gas (ABG)
• Chest X-ray should be requested. It is often normal in PE but abnormalities may be useful for differential diagnosis. If the patient is unwell request a portable X-ray
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTS), Glucose
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Listen to patient’s heart sounds
• 12 lead echocardiogram (ECG)
  • ECG changes in line with diagnosis of PE
    • Sinus tachycardia
    • Non-specific ST segment changes
    • T-wave abnormalities
    • Right axis deviation
    • Right bundle-branch block
• If concerned attach patient to cardiac monitor
• Call for senior help
• Check urine output and consider catheterisation
• Intravenous (IV) fluids as required by clinical picture and balanced with patients’ risk of fluid overload. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Discuss venous thromboembolism prophylaxis with senior as this will be dependent on diagnosis

Response

Management

• Two-Level PE Wells score

Clinical signs and symptoms of DVT	No    0	Yes    +3
PE is primary diagnosis or equally likely	No    0	Yes    +3
Heart rate > 100bpm	No    0	Yes    +1.5
Immobilisation for ≥ 3 days or surgery in the previous 4 weeks	No    0	Yes    +1.5
Previous, objectively diagnosed PE or DVT	No    0	Yes    +1.5
Haemoptysis	No    0	Yes    +1
Malignancy with treatment within 6 months or palliative	No    0	Yes    +1

• Wells score > 4 PE likely and patient requires immediate Computed Tomography Pulmonary Angiogram (CTPA)
• Wells score ≤ 4 PE unlikely and D-dimer test required
• If D-dimer test positive then an immediate CTPA is required
• If D-dimer is negative consider an alternative diagnosis
• Immediate pharmacological management
• Following diagnosis of PE start anticoagulation as per trust guidelines with low molecular weight heparin

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Referral to respiratory team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• Review by respiratory team regarding future medical management