Clinical Findings

Neuro: Anxiety, restlessness, confusion, syncope

Resp: Cough, dyspnea, crackle on inspiration, tachypnea, hemoptysis, wheezing.

CV: Pleuritic chest pain, tachycardia, hypotension, JVD.

Skin: Diaphoresis, lower extremity edema, S/S of thrombophlebitis, DVT.

MS: Accessory muscle use.

Labs: Positive D-dimer, CT and V/Q scan also used in diagnosis of PE.

Possible Causes: Embolization of thrombi from deep veins of the femur, pelvis, and lower extremities from multiple causes including venous stasis, hypercoagulable states, surgery and trauma, oral contraceptive and estrogen replacement therapy, pregnancy, malignancy.

Collaborative Management

Massive PE may result in cardiogenic shock and sudden death.

• Establish and support ABCs—Treat life-threatening emergencies immediately.
• Immediately activate RRT and notify HCP STAT.
• Monitor VS frequently—HR increases d/t hypoxemia; BP decreases in massive PE d/t decreased left heart preload; tachypnea may occur d/t decreased oxygenation and pain; fever may develop d/t inflammatory response.
• Monitor for sudden-onset pleuritic-like CP with dyspnea and tachypnea—usually first sign of acute PE, resulting from release of inflammatory mediators.
• Monitor labs: Initial ABGs reveal respiratory alkalosis d/t tachypnea and reduced PaO₂ d/t increased dead-space ventilation. Subsequent ABGs will show metabolic acidosis d/t hypoxia; Increased lactic acid levels confirm anaerobic metabolism; Coagulation studies include aPTT if Pt on heparin and PT-INR if on warfarin.
• Monitor UO—anything <0.5 mL/kg/hr is an early sign of shock.
• Position Pt with head of bed elevated to enhance breathing.
• Obtain IV access and administer IVF as ordered—use caution in RV overload.
• Administer STAT medications as ordered:
• If Pt stable: anticoagulants to inhibit PE growth or new clots from forming.
• If Pt unstable: thrombolytics to reduce size of clot; inotropic agents to improve CO; norepinephrine or vasopressin to maintain SBP 80 mm Hg.
• Institute bleeding precautions by minimizing venipunctures and watching for blood in urine, stool, and sputum and for unusual bruising.
• Auscultate lung sounds for crackles on inspiration or wheezing.
• Assess for leg vein tenderness and ascertain history of recent surgery, immobilization, recent DVT, malignancy.
• Assist with obtaining lab and diagnostic studies (D-dimer, PTT, ABG, CXR, V/Q scan, CT scan, pulmonary angiogram).
• Assist with intubation and resuscitation if necessary.
• Transfer to ICU for high-acuity care or thrombolytic therapy.