Transcript Massive Pulmonary Embolism: A Story of Survival

Kimberly Brown, MSN, RN, CCRN
Erica DeBoer, RN, MA, CNL, CCRN
Sanford USD Medical Center
Sioux Falls, South Dakota
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Identify patients at risk for pulmonary embolism
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Describe diagnostic tests for pulmonary embolism
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Verbalize interventions used to treat massive pulmonary
embolism and subsequent strategies to optimize patient
outcomes
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Describe the implications of utilizing new technologies
during CPR that may lead to positive outcomes
61 year old male
At home with his wife and functioning
independently
 1 week post cervical fusion
(anterior approach)with
cervical collar in place
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How do people end up with
Pulmonary Embolisms?
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A clot can form and impede
blood flow causing swelling
and pain.
◦ When a clot breaks off and
moves through the bloodstream,
this is called an embolism.
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Primarily affects the large
veins in the thigh.
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Venous thromboembolism is the 3rd most
common cardiovascular illness after acute
coronary syndrome and stroke
There are approximately 900,000 of VTE/PE
in the United States each year
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Nearly 67% of all VTE events result from
hospitalization
 Approximately 300,000 of these patients die
 Pulmonary embolism is the 3rd most common cause of
hospital-related death
 Most common preventable cause of hospital-related
death
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The Joint Commission has established guidelines
for VTE prophylaxis for this specific reason
 Pulmonary
Embolism refers to
obstruction of the pulmonary artery
or one of its branches by material
(eg, thrombus, tumor, air, or fat) that
originated elsewhere in the body
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Surgery
Sedentary Lifestyle
Obesity
Advancing Age
Genetic Predisposition
Cancer
Cardiovascular Disease
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Endovascular Damage
Estrogen
Family History
Immobility
Inflammation
Pregnancy
Smoking
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88% on NRB
On arrival to the ED, 1-2 word dyspnea
Continuous vomiting
Vital Signs
BP 67/50
HR 41
Temp 98.2
RR 14
O2 sat
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EKG
Chest xray
D-Dimer
Echo
CT Pulmonary Angiography
VQ Scan
Pulmonary Angiography
Vital Signs
BP 67/50
HR 41
Temp 98.2
RR 14
O2 sat
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BiPAP 7/10 to manage
airway temporarily due to
probable difficult intubation
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Heparin and antibiotics
initiated
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Central line placed
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Intubation performed per
anesthesia
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Levophed initiated
Admission
pH
Pre Intubation
Post Intubation
7.21
7.09
7.19
pCO2
53
73
61
CO2
23
24
25
BE
-7
-8
-5
pO2
45
55
115
O2 sat
70
74
97
HCO3
21
22
23
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Emergent Cardiology consult
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ECHO revealed pulmonary hypertension and
right ventricle dilation suspicious for
pulmonary embolism (PE)
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Chest CT (angio) – Bilateral PE
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Anticoagulation
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Thrombolytics
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IVC Filter
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Embolectomy
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Reduce propagation of existing clot
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Prevention of new clot formation or
embolization
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Adverse effects: bleeding, HIT
tPA - Tissue Plasminogen Activator
Indication for use - PE that causes hemodynamic
instability
 Goal – Dissolve/lysis of the clot
 Fast acting
 Can be used systemically and/or directly injected
into the clot
 Adverse Effects- severe bleeding
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ABSOLUTE INDICATIONS
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Recurrent VTE
Hypercoagulable state
Contraindications for high
dose anticoagulation
RELATIVE INDICATIONS
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Free floating VTE
Massive PE
Ineffective anticoagulation
therapy
Complications with
anticoagulation therapy
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Trauma
Prolonged surgical procedures
Medical conditions such as Afib
Prolonged immobilization
Long bone fractures
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Manual clot removal
 In the CCL or Interventional Radiology with sheath and
catheters
 Via a small incision
Last resort when thrombolytics are contraindicated or
ineffective
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What are your priorities?
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Key risk factors to consider?
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Systemic lytic therapy was initiated following
consult with a neurosurgeon
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CCU admission with poor prognosis
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HR – 20-30s
SBP 40 to 50s
Code blue called – PEA identified
Maxed out on pressors, multiple rounds of epi
and atropine
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Mechanical CPR
Impedence threshold device
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A recent randomized study published after the 2010
Consensus Conference
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ITD paired with manual ACD-CPR found that 9% of patients
treated with this combination survived to discharge with
favorable neurological function, compared with 6% in the
control group.
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This effect persisted for one year, demonstrating long-term
efficacy as well.
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Code continued while Sam was prepped for
transport to Cath Lab for lytic therapy for
lysing thrombus
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Day 1
 Nasal/oral bleeding
 ENT consult
 Hbg 9.7 -- 4 units PRBCs
 Low UO
 Alert and oriented
 Agitation and hypertension
 Worsening neck/facial swelling
 Neck hematoma discovered
 Bronch revealed partially obstructed ETT
 To OR for evacuation
 Hemodialysis started 2 L off
 Ventilator weaned to CPAP
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Day 14 - Trach placed
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Day 23- Transferred to the step down unit
 Off dialysis – AKI still present and managing with
diuretics
 Home with wife
 Continued therapies
 Neurologically Intact!
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Identification and management of risk factors
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High quality CPR utilizing technology
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Understanding of interventions for massive
pulmonary embolism
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Management strategies for post arrest
pulmonary embolism patients
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