PULMONARY

EMBOLISM
EFREN EZEKIEL ALBIOS
SHIELA MAE TURNO
PULMONARY EMBOLISM
- Is the blockage in one of the pulmonary arteries in your
lungs.
 RISK FACTORS SIGNS & SYMPTOMS
 Have been inactive or immobile
for long periods of time.

 Smoking cigarettes.

 Obesity

 Having had recent injury or trauma to a vein. Shortness of Breath Chest Pain

 Having diseases such as stroke, paralysis,

chronic heart disease, or high blood
pressure.

 Are having surgery or have broken a bone

 Women taking oral contraceptives

Hemoptysis
PATIENT PROFILE Name: M. V.
Sex: Male
Age: 52 y/o

CC:
“My chest hurts and I feel
like I can’t get enough air.”

HTN Type 2 DM
(12years) (10years)

Chronic
Diabetic
wound
Neuropathy
infxn.

BKA left leg Obesity

History of Present Illness
1. Gangrenous chronic wound infection on left ankle

2. S/P BKA left leg (postop day #11)

3. Sharp chest pain and shortness of breath.

4. Refuse physical therapy in the skilled nursing unit.

5. Denies N&V, dizziness and is feeling anxious

6. Non-productive cough and has been having

trouble with deep inspiration since yesterday
Family • Father has Type 2 DM
History
• The patient performs with a local rock

Social band and leads an unhealthy lifestyle

(poor diet, no exercise).
• Significant for tobacco abuse (20
pack-year history).

History • Denies illicit drug use.

• Drinks alcohol socially on the
weekends.
 CURRENT MEDICATIONS/TREATMENT
MEDICATIONS DOSE INDICATION Glucose 150 2 units
Novolin 70/30 40 units every AM Type 2 Diabetes to 199 mg/dL
30 units every PM
Lisinopril 10mg PO once Hyperternsion Glucose 200 4 units
daily to 249
Unfractioned 5,000 units SC q Anticoagulant mg/dL—
Heparin 8hrs. Glucose 250 6 units
Nicotine TD 21mg per day Smoking to 299
Patch cessation mg/dL—
Cefepime 2g IV every 24 hours Antibacterial Glucose 300 8 units
Vancomycin 2g IV every 24 hours antibacterial to 349
mg/dL—
Meperidine 50mg PO every Relieve sever
4-6 hours/PRN for pain Glucose
pain greater than
Metformin 500mg PO 2x Type 2 Diabetes or equal to
daily 350 mg/dL
PHYSICAL EXAMINATION
Skin: warm and dry
HEENT: Head: Atraumatic; PERRLA; EOMI
Neck/Lymph Nodes: No carotid bruits; no
lymphadenopathy
Lungs/Thorax: Clear to auscultation bilaterally; no
wheezing or crackles
CV: RRR; normal heart sounds; no murmurs, rubs, or
gallops
Abd: Soft; NT/ND; good bowel sounds
Genit/Rect: patient refused at this time
MS/Ext: S/P BKA left leg; range of motion within normal
limits; no swelling or redness; no cyanosis
Neuro: No focal deficits noted; cranial nerves intact
ECG: Normal sinus rhythm at 88 bpm. No Q waves or ST
changes present. No ectopy. Normal QRS axis, normal
QRS morphology.
 LABORATORY RESULTS
Normal Values Laboratory Results Normal/Low/High
Na 136-145 mmol/L 140 mEq/L Normal
K 3.6-5.2 mmol/L 4.3 mEq/L Normal
Cl 100-108 mmol/L 102 mEq/L Normal
CO2 23-29 28 mEq/L Normal
BUN 8-20 mg/dl 18 mg/dL Normal
SCr 0.7-1.55 mg/dL 1.6 mg/dL High
Glu 70-100 mg/dL 125 mg/dL High
HgB Male: 14-18 g/dL 14 g/dL Normal
Hct 0.37-0.54% 40% Normal
Plt 150-450 x 109/L 61 × 103 /mm3 Low
WBC 4-11 x 109/mm3 8 × 103 /mm3 Normal
Albumin 3.5-5.5 g/dL 4.3 g/dL Normal
AST 100-200 IU/L 19 IU/L Low
ALT IU/L 11 IU/L
Alkaline Phosphatase 30-120 u/L 76 IU/L Normal
D-Dimer ≤500 885 ng/mL High
 CARDIAC ENZYMES
Normal (Time: (Time:0
Values 0305) 915)
CK 40- 32 IU/L NORMA 30IU/L NORM
200IU/L L AL
CK-MB 5-25 0.4 IU/L NORMA 0.4IU/L NORM
L AL
Troponi ≤0.01ng/m 0.01ng/m NORMA 0.01ng/mL NORM
nI L L L AL

ECG
ASSESSMENT CLINICAL COURSE
Chest pain, SOB Thrombocytopenia patient was transferred to
- most likely non-cardiac, - R/O heparin-induced a monitored unit
R/O PE, R/O pneumonia thrombocytopenia (HIT)

Chronic wound infection, V/Q scan was ordered.

Diabetes mellitus
S/P BKA
- blood glucose well
- continue current antibiotic
controlled on current
regimen to complete 14
medications and hospital no-
days, continue wound care
added sugar diet
and pain management chest x-ray and spiral CT
of the chest were ordered
but spiral CT was later
cancelled
HYPERTENSION
- stable on current regimen
platelet count history was
obtained from the skilled
nursing unit.

Chest x-ray report: no evidence of acute
cardiopulmonary disease. Cardiac enzymes
(second set):
CLINICAL COURSE
V/Q scan report: multiple segmental perfusion defects,
indicating a ventilation perfusion mismatch and high
probability of pulmonary embolism (Fig. 16-1).
Platelet count history from skilled nursing unit:
QUESTIONS
 PROBLEM IDENTIFICATION
1A. What subjective and objective information is consistent with a
diagnosis of PE in this patient?

Subjective:
Sharp Chest pain &
Objective:
Shortness of Breath Ventilation/Perfusion(V/Q)
mismatch
RR & D-dimer above normal
range
 1B. What risk factors for PE are present for this patient?

Surgery
High Blood (Below Knee Prolonged
Smoking Pressure Amputation left Obesity
immobilization
leg)
 Condition Remarks Basis Score
Thrombocytopenia >50% Platelet fall to nadir Day 0, or Post-op Day 4 2
refers to the day prior to the
1C. >20 administration of UFH (basis
for Plt count), while Day 6 or
Calculate Post-op Day 11 where he
was transferred to the
this monitoring unit.
patient’s %Plt= (PltDay 0 - PltDay 6)
pre-test ___________________
probability PltDay 0

score for = ( 231 – 61) x

103/mm3
HIT?
_______________________
__
231 x 103
mm 3

=73. 36%

Thus,73.59%> 50%

Timing of Onset for Platelet Day 5-10, or <= day 1 with Onset: Day 1 2
fall recent heparin past 30 days
Thrombosis or other Progressive, or recurrent Suspected thrombosis 1
thrombosis, erythematosus
sequelae skin lesions, suspected
thrombosis (not proven)
Other causes of platelet fall No other cause No other cause 2
1D. Develop a list of the potential drug therapy problems related to this patient’s
increased serum creatinine.
Drug Informations
Metformin It increases serum creatinine level
and lactic acidosis may also occur.
Lisinopril An ACE inhibitor that increases na
BUN and serum creatinine levels. It
also causes hypotension and renal
dysfunction.
Vancomycin Causes vancomycin-induced
toxicity
Heparin Increases the risk of hyperkalemia
w/ ACE inhibitors which could lead
to renal impairment
Cefepime Induced a significant increase in
urine, urea and creatinine
concentrations and significant
decrease in their clearance.
 DESIRED OUTCOMES
2A. What are the goals of therapy for the treatment of PE?

keep new clots from

to stop the blood clot forming/prevent the INR between
from getting bigger recurrence of 2.0 to 3.0
thrombus.

2B. What additional goals of therapy exist for this patient

with HIT?

Avoid
Reduce cost, Prevent post-
complications
morbidity and thrombotic
associated w/
mortality syndrome
thrombosis
 THERAPEUTIC ALTERNATIVES
3A. Which agents are available to initiate anticoagulations for the treatment of PE in
this patient?

Unfraction Novel Oral Anticoagulants

LMW alternative to Vit. K
ated antagonist (VKA) for the
Heparin Heparin first 3 months of the
treatment

3B. What non-anticoagulant alternatives (pharmacological/non-pharmacological) are available? Is

this patient an appropriate candidate for any of these alternatives?

Thrombolytic Intermitted Compression Foot Pumps Physical

therapy (but Pneumatic Stockings Therapy
not indicated Compression
for the (IPC)
patient)
 OPTIMAL PLAN
4A. Choose an appropriate anticoagulant to initiate therapy and calculate the dose
for this patient.
4B. When can Warfarin be started for long-term management of PE in this patient?
Design a pharmacotherapeutic plan for the transition to Warfarin.
 CLINICAL COURSE
heparin-induced platelet
antibody ELISA
An order was written to
The patient was started (enzyme-linked
avoid all heparin
on an IV infusion of immunosorbent assay)
(including catheter
lepirudin at 10:00 AM. A was drawn and sent to
flushes).
an outside laboratory for
confirmation of HIT.

Prior to initiating lepirudin, a baseline

aPTT (27.3 sec; reference: PT (11.1 sec; reference:
INR (1.0)
23.8–34.6 sec), 9.8–12.3 sec), and

were obtained to assist with anticoagulation dosing.

 OUTCOME EVALUATION
5A. Determine the therapeutic aPTT range for the direct
thrombin inhibitor administered to this patient.
AC Day AC Time Lepirudin Warfarin aPTT (sec) aPTT Ratio aPTT PT(sec)/INR Plt
Dose Dose (solution) Ratio Count
1 10:00 AM 40.8 mg/hr, Not given 27.3 27.3/27.3 1 11.1/1.0 61
for 15-20
seconds

15.3mg/hr, for
then rest of
the hour
2:00 PM 15.3mg/hr, 61.0 61/27.3 2.23

6:00 PM 15.3mg/hr, 60.4 60.4/27.3 2.21

2 6:15 AM 15.3mg/hr, Not given 59.5 59.5/27.3 2.18 12.9/1.1 89

3 6:05 AM 15.3mg/hr, Not given 64.4 64.4/27.3 2.36 13.3/1.1 96
4 5:57 AM Not given 79.2 79.2/27.3 2.90 14.1/1.2 117
5B. After reviewing the dosing information in Table 16-2, determine what lepirudin
dosage adjustment is necessary on day 4 to maintain this patient within the
therapeutic aPTT range.
5C. What clinical and laboratory parameters will you use to monitor the efficacy and
safety of anticoagulation in this patient?
 PATIENT EDUCATION
6A. Prior to discharge, what information should be provided to this patient about
warfarin therapy to enhance compliance and ensure efficacy and safety?
6B. Discuss the information that you will provide to this patient concerning the future
use of heparin and low molecular weight heparin therapy.