http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 1, FEBRUARY 2007 39 Kathleen Shaughnessy is the clinical director of cardiothoracic surgery at Abington Memorial Hospital, Abington, Pa. Corresponding author: Kathleen Shaughnessy, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001 (e-mail: [email protected]). To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899- 1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. The patient’s hemodynamic sta- bility provided the multidisciplinary team with an opportunity to perform diagnostic tests to look for a possible cause for the cardiac arrest. A 2- dimensional echocardiogram showed dilatation of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pres- sures of 60 to 65 mm Hg, all abnor- mal findings in a healthy heart. This result, coupled with the postpartum arrest, led to a tentative diagnosis of pulmonary embolism. A ventilation/ perfusion scan indicated a high probability of pulmonary embolism, and a computed tomography scan of the thorax showed a saddle embolism, which confirmed the diagnosis. The definitive diagnosis of pul- monary embolism proved a great threat to the patient’s survival, and an urgent interdisciplinary team meeting ensued. Physician represen- tatives from obstetrics, cardiology, pulmonary medicine, and cardio- thoracic surgery, as well as a variety of nursing representatives who directly provided care for the patient, played a crucial part in the decision- making process. The critical care nurses reported decerebrate postur- ing of the patient after the cardiac arrest, which may be indicative of Kathleen Shaughnessy, MSN, CRNP, CCRN W henever a “Code Blue Maternity” is announced over the hospital’s loudspeaker, a collective sigh and silent prayer go up among the staff. Such an event is especially traumatic to hospital personnel dur- ing the holiday season. Our surgical intensive care and maternity units are worlds apart, but these worlds collided one December afternoon when a 35-year-old patient, whom we will refer to as Shelby, had a car- diac arrest shortly after an unevent- ful cesarean-section delivery at 35 weeks’ gestation. The delivery had produced a healthy, beautiful baby girl. Reports of the patient becoming acutely dyspneic, hypotensive, syn- copal, and suffering cardiac arrest quickly filtered through the hallways. Only moments after the code blue maternity was called, a group of emergency personnel responded to the scene. In conjunction with the medical professionals already pres- ent, they acted without hesitation to save this patient. Pulseless electrical activity was quickly identified at the beginning of the code, and cardiopulmonary resus- citation was initiated. The patient was immediately intubated and ventilated with 100% oxygen. Boluses of intra- venous epinephrine and atropine were then given, followed by an infusion of isotonic sodium chloride solution. The patient responded to treatment, as evi- denced by reestablishment of a pulse and adequate blood pressure. ClinicalArticle Author Massive Pulmonary Embolism * This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Identify patients at risk for a massive pulmonary embolus 2. Describe current assessment and diagnostic strategies for pulmonary embolus 3. Summarize possible medical and surgical interventions for pulmonary embolus 4. Discuss goals of treatment in the care of patients with pulmonary embolus by AACN on May 10, 2018 http://ccn.aacnjournals.org/ Downloaded from
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http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 1, FEBRUARY 2007 39
Kathleen Shaughnessy is the clinical director of cardiothoracic surgery at Abington Memorial Hospital, Abington, Pa.
Corresponding author: Kathleen Shaughnessy, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001 (e-mail: [email protected]).
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].
The patient’s hemodynamic sta-
bility provided the multidisciplinary
team with an opportunity to perform
diagnostic tests to look for a possible
cause for the cardiac arrest. A 2-
dimensional echocardiogram showed
dilatation of the right ventricle and
moderate tricuspid regurgitation
with pulmonary artery systolic pres-
sures of 60 to 65 mm Hg, all abnor-
mal findings in a healthy heart. This
result, coupled with the postpartum
arrest, led to a tentative diagnosis of
pulmonary embolism. A ventilation/
perfusion scan indicated a high
probability of pulmonary embolism,
and a computed tomography scan of
the thorax showed a saddle embolism,
which confirmed the diagnosis.
The definitive diagnosis of pul-
monary embolism proved a great
threat to the patient’s survival, and
an urgent interdisciplinary team
meeting ensued. Physician represen-
tatives from obstetrics, cardiology,
pulmonary medicine, and cardio-
thoracic surgery, as well as a variety
of nursing representatives who
directly provided care for the patient,
played a crucial part in the decision-
making process. The critical care
nurses reported decerebrate postur-
ing of the patient after the cardiac
arrest, which may be indicative of
Kathleen Shaughnessy, MSN, CRNP, CCRN
Whenever a “Code Blue
Maternity” is announced over the
hospital’s loudspeaker, a collective
sigh and silent prayer go up among
the staff. Such an event is especially
traumatic to hospital personnel dur-
ing the holiday season. Our surgical
intensive care and maternity units
are worlds apart, but these worlds
collided one December afternoon
when a 35-year-old patient, whom
we will refer to as Shelby, had a car-
diac arrest shortly after an unevent-
ful cesarean-section delivery at 35
weeks’ gestation. The delivery had
produced a healthy, beautiful baby
girl. Reports of the patient becoming
acutely dyspneic, hypotensive, syn-
copal, and suffering cardiac arrest
quickly filtered through the hallways.
Only moments after the code blue
maternity was called, a group of
emergency personnel responded to
the scene. In conjunction with the
medical professionals already pres-
ent, they acted without hesitation to
save this patient.
Pulseless electrical activity was
quickly identified at the beginning of
the code, and cardiopulmonary resus-
citation was initiated. The patient was
immediately intubated and ventilated
with 100% oxygen. Boluses of intra-
venous epinephrine and atropine were
then given, followed by an infusion of
isotonic sodium chloride solution. The
patient responded to treatment, as evi-
denced by reestablishment of a pulse
and adequate blood pressure.
ClinicalArticle
Author
Massive PulmonaryEmbolism
* This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:
1. Identify patients at risk for a massive
pulmonary embolus
2. Describe current assessment and diagnostic
strategies for pulmonary embolus
3. Summarize possible medical and surgical
interventions for pulmonary embolus
4. Discuss goals of treatment in the care of
patients with pulmonary embolus
by AACN on May 10, 2018http://ccn.aacnjournals.org/Downloaded from
46 CRITICALCARENURSE Vol 27, No. 1, FEBRUARY 2007 http://ccn.aacnjournals.org
echocardiography can show thrombi
within the central pulmonary
artery.21
Moderate to severe tricuspid
regurgitation due to right ventricular
pressure overload leads clinicians to
suspect pulmonary embolism. The
finding of severe tricuspid regurgita-
tion on Shelby’s transthoracic echocar-
diogram provided the first clue to the
diagnosis of pulmonary embolism.
Nurses should inform nonintubated
patients that a transthoracic echocar-
diogram is a surface ultrasound image
obtained by placing a probe over the
chest to identify cardiac chambers,
valves, and the pulmonary artery.
The patient will feel pressure as the
technician glides the probe over the
chest wall. If a nonintubated patient
is scheduled for transesophageal
echocardiography, the nurse should
explain that the patient will be lightly
sedated and a probe will be passed
into the esophagus to assess the heart
and pulmonary artery more accu-
rately. Reassure the patient that he
or she will not recall the procedure.
Pulmonary angiography or aor-
tography is the reference standard
test for diagnosing pulmonary
embolism. Catheterization of the
right side of the heart with injec-
tion of contrast dye allows direct
visualization of the pulmonary vas-
culature and identification of areas
of obstruction. This test must be
performed when pulmonary
embolism cannot be reliably diag-
nosed or excluded by means of non-
invasive testing22 (Table 3). The
nurse explains that a catheter is
inserted into the femoral or brachial
artery and dye is injected thorough
the catheter in order to visualize the
pulmonary arteries and identify
areas of obstructed blood flow.
Goals of TreatmentThe goals of medical and/or sur-
gical interventions (Table 4) are to
relieve pulmonary obstruction, stop
clot propagation, regain or main-
tain hemodynamic stability, pre-
vent clot recurrence, and prevent
pulmonary hypertension.
Management of Pulmonary EmbolismMedical Management
Circulatory
Support. Medical
interventions for
treating massive
pulmonary
embolism are
aimed at preserv-
ing circulatory
support by maintaining blood pres-
sure, managing the airway, and pre-
venting new thrombus formation.
Airway management and oxygen
administration are paramount in the
treatment of pulmonary embolism.
Mechanical ventilation is often
required to maximize oxygen delivery
to the patient with circulatory col-
lapse. Cautious use of sedatives dur-
ing induction is warranted as these
drugs can blunt the catecholamine
Table 3 Diagnostic tests for pulmonary embolism
Diagnostic test
Electrocardiography
Chest radiography
Arterial blood gas analysis
D-dimer assay
Duplex ultrasonography
Ventilation/perfusionscintigraphy
Helical (spiral) computedtomography
Echocardiography
Aortography
Highlights
Rule out myocardial infarction, aortic dissectionAnterior T-wave inversion common in pulmonary embolismStrain pattern in right side of heart (S wave in lead I, Q
wave in lead III, T-wave inversion in lead III), new rightbundle branch block, and right-axis deviation seen inpulmonary embolism
The Westermark sign, the Hampton hump, and pleural effusion in pulmonary embolism
Rule out other causes of dyspnea
PaO2 < 80 mm Hg and respiratory alkalosisNormal PaO2 does not exclude pulmonary embolism
90% negative predictive value if <500 mg/L
95% sensitivity and specificity for detecting deep venousthrombosis above knee
A low or indeterminate result does not eliminate diagnosisof pulmonary embolism
High accuracy for detection of emboli in main or lobarpulmonary arteries
New severe tricuspid regurgitation and pressure overloadin right ventricle in pulmonary embolism
Transthoracic echocardiography for detection of intra-cardiac thrombi
Transesophageal echocardiography for detection ofthrombi in central pulmonary artery
Reference standard testAllows direct visualization of pulmonary vasculature to
identify areas of obstruction
Table 4 Treatment of pulmonary embolism
Medical options
Volume resuscitation
Administration of vasopressors
Anticoagulation
Administration of thrombolytics
Surgical options
Catheter embolectomy
Placement of filter in inferiorvena cava
Surgical embolectomy
by AACN on May 10, 2018http://ccn.aacnjournals.org/Downloaded from
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CE Test Test ID C0713: Massive Pulmonary EmbolismLearning objectives: 1. Identify patients at risk for a massive pulmonary embolus 2. Describe current assessment and diagnostic strategies for pulmonary embolus3. Summarize possible medical and surgical interventions for pulmonary embolus 4. Discuss goals of treatment in the care of patients with pulmonary embolus
Program evaluationYes No
Objective 1 was met � �Objective 2 was met � �Objective 3 was met � �Objective 4 was met � �Content was relevant to my
nursing practice � �My expectations were met � �This method of CE is effective
for this content � �The level of difficulty of this test was: � easy � medium � difficult
To complete this program, it took me hours/minutes.
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. What is the annual incidence of pulmonary embolus resulting in maternaldeaths per 100 000 live births versus the pulmonary embolus death rate in thegeneral population per 100 000?a. 65 versus 2b. 70 versus 60c. 2 versus 65d. 7 versus 65
2. Which of the following is a risk factor for a pulmonary embolus?a. Recent surgery b. Recent emotional stressor c. Recent blood transfusion d. Recent placement of a central catheter
3. Which is of the following is a preventative nursing measure that can beimplemented in the hospital to reduce the risk of deep vein thrombosis?a. Compression stockings or pneumatic bootsb. Bed rest or limited mobilityc. Assessment of arms for pain, erythema, or size differencesd. Frequent D-dimers or leg ultrasounds
4. A massive pulmonary embolus occurs when a thrombus occludes more than what percentage of the pulmonary vasculature?a. 75%b. 50%c. 90%d. 40%
5. What do the main sources of thrombi in massive pulmonary embolus include?a. Carotid, upper extremities, and cardiac vasculatureb. Lower extremities, pelvis, and kidney vasculaturec. Lower extremities, upper extremities, and pelvis vasculatured. Upper extremities, pelvis and carotid vasculature
6. What is a single common characteristic shared by patients at risk forheparin-induced thrombocytopenia?a. Development of venous and arterial thrombosisb. Previous exposure to heparinc. Life- and limb-threatening complicationsd. Need for lifelong heparin treatment
7. What is the most common rhythm seen after a cardiac arrest related to a pulmonary rhythm?a. Pulseless electrical activityb. Ventricular fibrillationc. Asystoled. Tachycardia
8. What do the 3 classic signs and symptoms of a pulmonary embolusinclude?a. Gradual onset tachycardia, apnea, and feeling of apprehensionb. Acute onset dyspnea, hemoptysis, and chest painc. Acute onset tachycardia, tachypnea, and chest paind. Gradual onset dyspnea, tachypnea, and chest pain
9. How is the D-dimer test used to detect the presence of pulmonary embolus?a. If less than 500 mg/L it has a negative predictive value of 90% b. If greater than 500 mg/L it has a negative predictive value of 90% c. If less than 500 mg/L it has a positive predictive value of 90% d. If greater than 500 mg/L it has a positive predictive value of 90%
10. If clinical suspicion remains high after initial noninvasive test(s) butpulmonary emboli cannot be def initely diagnosed (possible false negativeresults), what is the standard reference test?a. Chest spiral computed tomographyb. Ventilation/perfusion scintigraphyc. Aortography d. Cardiac catherization
11. What is the standard treatment for pulmonary embolus in a stablepatient?a. Low-molecular-weight heparin injections followed by an unfractionated
12. What is a surgical intervention aimed at primary prevention of newpulmonary emboli?a. Direct thrombolytic therapyb. Insertion of inferior vena cava filter c. Surgical embolectomyd. Catheter embolectomy
13. What are the 2 main goals of circulatory support in patients with massive pulmonary embolus?a. Maintaining blood pressure with fluids and vasopressors along with providing
adequate oxygenationb. Avoiding hypertension with vasodilators and providing adequate oxygenationc. Provide support to the family while keeping the patient sedatedd. Early detection of embolus along with administering coumadi
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Test ID: C0713 Form expires: February 1, 2009 Contact hours: 1.5 Fee: $11 Passing score: 10 correct (77%) Category: A Test writer: Patti McCluskey-Andre, RN, MSN, ACNP-C/CCNS
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