A Report On Pulmonary Embolism- Assessment Answers

Some of the most common sources that lead to pulmonary embolism are pelvic vein embolus or proximal leg deep venous thrombi (Goodacre et al., 2014). Any of the risk factors of proximal leg deep venous thrombosis tend to increase the risk of the dislodging of the venous clot and migration to the lung circulations. Thrombosis usually develops because of a group of clauses that is known as Virchow's triad(Kahler, Moss Beam & Kline, 2014). The classical risk factors associated with embolic diseases. The people with advanced age, obesity, prolonged immobility, post-infarction periods, heart failure and pregnancy are predisposing for embolismic disease through venous stasis. The event such as local trauma , vasculitis, and previous thrombosis causes critical damage to the endothelium layer of the venous wall. Contraceptive pills Polycythemia and cancers, especially adeno-carcinomas, are associated with thrombosis disorders with an increased risk of pulmonary embolism. The absence or presence of risk factors for embolic disease is sparingly essential information for the diagnosis and evaluation of the likelihood of pulmonary embolism.

Diagnosis

“Although early treatment is highly effective, PE is underdiagnosed and, therefore, the disease remains a major health problem.”(Lavorini et al., 2013)

This condition is primarily considered to be under diagnosed since in most of the cases the symptoms are not specified and the results of the treatment are significant (Sanjeevi, 2012). One of the standard cares is the objective tests which generally either establishes or refutes the PE diagnosis have become a standard of care. This plan of care must be based on the clinical manifestation and evaluation of the chances of pulmonary embolism. The accuracy of these tests is very high when the results are in accordance with the overall assessment.

It is difficult to diagnose clinical symptom of pulmonary embolism. It is often asymptomatic which further add on to the level of difficulty. If the symptoms are present then it is found to be sparingly non- specific sometimes. Trachycardia, cough, loss of consciousness, chest pain and haemoptysis are some of the initial symptom of pulmonary embolism. Pain which is of pleurisy type are often because of PE which causes heavy irritation of pleura and are associated with pulmonary infiltration. It is associated with alveolar hemorrhage as per histopathology and with haemoptysis as a symptom. 

The chest X-ray scan is one of the major sources of help in ruling out other conditions (e.g. pulmonary edema, pneumonia, pneumothorax) and that have sparingly clear radiological findings and are of less use in the diagnosis of pulmonary embolism. In about 25% of cases of pulmonary embolism, the chests X-ray are found to be normal. In fact, this is of great assistance, as the coexistence of severe dyspnoea, with a ventilation-perfusion lung scan of even intermediate probability, is practically diagnostic for pulmonary embolism. The only diagnosis available is the haematological examination which is quite advance for of diagnosis that helps in the diagnosis of PE is the measurement and quantification of D-dimers with the ELISA (Enzyme linked immune sorbent assay) method. Although this method is extremely sensitive (i.e.>90%) but it is very non-specific. Since there is a presence of elevated levels of D-dimers in various other disease conditions that are clinically similar to pulmonary embolism, such as pneumonia, post-surgery trauma , cancer, myocardial infarction and heart failure, etc. In view of this, the most important contribution of D-dimers quantification is in ruling out pulmonary embolism when their levels are normal (i.e. high negative predictive values). Pulmonary angiography is one of the widely accepted techniques for the detection of pulmonary embolus within the circulation. It is basically performed whenever some noninvasive techniques and clinical data failed to diagnose the disease. It is an appropriate test to detect the patient with unstable hemodynamics.

Therefore, it can be observed that the diagnosis of this condition is based on the valid clinical criteria and selective tests (Bergrem et al., 2013). This is primarily because the clinical presentations could not be distinguished from the other causes that arise from chest pain and breathe shortage.

Treatment

One of the known treatments of this condition is Anticoagulant therapy and this is one treatment that would definitely prevail. Intensely, there are also other supporting treatments that are available such as analgesia along with this treatment(Kabrhel, 2013). Mostly the people are admitted in the hospitals during the early stages of the disease and they usually remain under the care unless the INR has reached the appropriate therapeutic levels(Tapson, 2012). Nonetheless, the lower level risks can be managed in the homes itself and such a home treatment is common for this condition.

The major cornerstone therapy for pulmonary embolism is to prevent the recurrence of new embolism by regular dosage of anticoagulants or a filter in the inferior vena cava, since it has been seen that the majority of the patients die due to continue deterioration in health because of formation of new emboli again and again. It is necessary to attempt the primary lysis of the embolus when the person is in haemodynamic condition or in shock.

• Supportive Therapy- The patients present with Hypoxaemia responds to oxygen administration since main patho-physiological mechanism is due to oxygen supply disturbances. Bed rest is often recommended and it helps in two ways. Firstly, it lessens the oxygen consumption which ultimately decreases the requirement of high cardiac output. Secondly, less movement will not allow the embolus to get detached from its peripheral location.
• Anticoagulant Therapy- The basic treatment of pulmonary embolus is heparin treatment which prevents the formation of thrombi and facilitates the physiological endogenous fibrinolysis to dissolve the older ones. It is recommended to start the heparin treatment even before the diagnosis of the pulmonary embolism. Low molecular weight heparin has been found safer and effective which is now being used for the dissolving hemodynamic stable pulmonary embolus.
• Filter placement - The use of filters in the inferior vena cava is indicated in the case of pulmonary embolus where there are problems and contraindications for use of anticoagulants or when there is formation of thrombi even after anticoagulant therapy. A filter doesn’t appear to facilitate out in case of proximal DVT with freely floating thrombus.
• Thrombolysis- This therapy must be applied to the patient with circulatory shock and hemodynamic instability immediately. The patient with stable blood pressure, there is no objection in applying thrombolytic therapy. Thrombolytic therapy directly improves the heart function while at the same time significantly reduces the recurrence of new thrombi.
• Embolectomy- The patients with hemodynamic instability and in which the thromolytic treatment has failed, transvenous catheter embolectomy is done. Due to the advancement in technology, various tools has been developed which can aspire out the emboli from the pulmonary circulation. Surgical thrombus removal is suggested if such a therapy fails to suck out the thrombus from the circulation. Although the success rate is still not accepted for embolectomy as the patients in whom it is done are already in very critical condition. Some reports suggested that 58% of the patient death occur during emergency embolectomy due to heart attack. Cardiogenic shock and cardiac arrest are the major two risk factors in case of this treatment. Hemodynamic stabilization and rapid diagnosis plays a major role in result improvement. Pulmonary endarterectomy with hypertension in the patients and evidence of embolism on pulmonary angiography has been reported in various literatures. Pulmonary hypertension and hemorrhage are the two main causes of mortality in case of pulmonary embolism.

Conclusion

Pulmonary embolism is among the top three biggest cause of death from cardiovascular diseases after cerebro-vascular stroke and myocardial infarction in today’s world. After the diagnosis the mortality rate of pulmonary embolism is reached up to 15% within in 3 months. Since pulmonary embolism symptoms occur only in the 30% patients so it is very important to diagnose this disease at an early stage. The risk factor is associated to the people taking contraceptive pills, having cancer, pregnancy, undergoing hormonal therapy etc. Various methods are available for the diagnosis but it is really difficult to detect PE at an early stage so most of the diagnostics method fails. Treatment like anticoagulant therapy is widely accepted and shown promising results for dissolving and inhibiting the recurrence of new embolus. Therefore it is very important to detect this disease at early stage in order to save the patient from life threatening experience.

References

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Bergrem, A., Dahm, A., Jacobsen, A., Sandvik, L., &Sandset, P. (2013). OC-16 Differential risk factors for pregnancy-related deep vein thrombosis and pulmonary embolism – Results from a population-based case-control study. Thrombosis Research, 131, S75.doi:10.1016/s0049-3848(13)70042-2

Goodacre, S., Nelson-Piercy, C., Hunt, B., & Chan, W. (2014). When should we use diagnostic imaging to investigate for pulmonary embolism in pregnant and postpartum women?. Emergency Medicine Journal, 32(1), 78-82.doi:10.1136/emermed-2014-203871

Kabrhel, C. (2013). A Multidisciplinary Pulmonary Embolism Response Team. Chest, 144(5), 1738.doi:10.1378/chest.13-1562

Kahler, Z., Moss Beam, D., & Kline, J. (2014). 91 Physician Attitudes Toward Immediate Discharge of Low-Risk Pulmonary Embolism Patients from the Emergency Department. Annals Of Emergency Medicine, 64(4), S33.doi:10.1016/j.annemergmed.2014.07.116

Lavorini, F., Di Bello, V., De Rimini, M., Lucignani, G., Marconi, L., &Palareti, G. et al. (2013). Diagnosis and treatment of pulmonary embolism: a multidisciplinary approach. Multidisciplinary Respiratory Medicine, 8(1), 75.doi:10.1186/2049-6958-8-75

Piovella, F., &Iosub, D. (2015). Acute pulmonary embolism: risk assessment, risk stratification and treatment options. The Clinical Respiratory Journal, n/a-n/a. doi:10.1111/crj.12264

Sanjeevi, C. (2012). Autoimmune diseases and risk of pulmonary embolism. The Lancet, 379(9812), 200-201.doi:10.1016/s0140-6736(11)61510-9

Stansby, G., &Berridge, D. (2013). Venous thromboembolism. British Journal Of Surgery, 100(8), 989-990. doi:10.1002/bjs.9187

Tapson, V. (2012).Advances in the Diagnosis and Treatment of Acute Pulmonary Embolism. F1000 Med Rep, 4.doi:10.3410/m4-9