| Pulmonary embolism is a sudden blockage of the arterial circulation of the lungs. The blockage can occur in the main artery carrying blood from the heart to the lungs (pulmonary artery) or in the smaller arteries within the lung. The blockage usually arises from a blood clot originating in the veins of the legs that breaks loose, travels to the heart, and on to the pulmonary artery. However, many other substances are known to embolize the pulmonary circulation. These may include air (from a central vein catheter), amniotic fluid (dislodged in active labor), fat (arising from long bone fractures), foreign bodies (i.e., talc introduced during intravenous drug use), septic emboli (in acute endocarditis), or tumor cells.
In most cases, blockage is temporary and causes no symptoms. In others, the blockage can cause chest pain with shortness of breath, cough, and coughing of blood. Other symptoms such as sweatiness, anxiety, fainting (syncope), and rapid heart rate may occur. A massive pulmonary embolism can put enormous stress on the right ventricle and halt the entire circulation system causing cardiopulmonary arrest. Pulmonary embolism can cause permanent lung damage through the death of lung tissue (pulmonary infarction).
Risk factors for pulmonary embolism can include prolonged bed rest or inactivity, surgery, femur or pelvic trauma or surgery, central vein intravenous lines (central vein catheters), cancer, endocarditis, childbirth, stroke, congestive heart failure, frequent air travel, and obesity.Incidence and Prevalence: Approximately 60% of individuals with blood clots in the deep veins of their upper legs (proximal deep vein thrombosis) develop pulmonary emboli. Of those individuals who develop pulmonary embolism, 10% die within the first hour and 30% will die subsequently from recurrent pulmonary embolism if undiagnosed and untreated (Sharma).
There are an estimated 630,000 cases of pulmonary embolism occurring in the US each year (Dalen). Death occurs within 1 hour for approximately 67,000 of those individuals. Of those that survive the first hour, 400,000 will not be diagnosed and 120,000 will die. Of the 163,000 individuals that survive the first hour and are diagnosed only 13,000 will die and the rest survive. Early diagnosis is important to survival. |
Source: Medical Disability Advisor
| History: The individual usually experiences sudden shortness of breath with chest pain that may radiate to the shoulder, jaw, neck or arm. The chest pain may be described as worse with deep breathing (pleuritic). This may be combined with fainting, sweating, coughing up blood or anxiety. The individual may complain of a rapid heartbeat or palpitations. Physical exam: Typical findings include a rapid pulse, chest pain, fainting, and shortness of breath. Some individuals may present with a low-grade fever, cyanosis, abnormal lung sounds, and wheezing. Listening to the chest may reveal distinct patterns in heart sounds and blood flow. The individual will usually have a fever, high pulse rate and rapid breathing if the embolism resulted in an infarction. In cases of massive embolism, the individual will display signs of shock (cold, clammy skin, weak pulse, and low blood pressure). Tests: Tests typically include chest x-ray, electrocardiogram, lung scan, and arterial blood gases. A new blood test is D-dimer. Lung scans (ventilation/perfusion lung scans) are an important test for diagnosing pulmonary embolism and can be combined with color ultrasounds of the legs to diagnose blood clots in the leg veins. A pulmonary angiogram is the most definitive test to diagnose the presence of pulmonary emboli. A spiral CT scan or MRI may be ordered on occasion as a noninvasive alternative for diagnosis. |
Source: Medical Disability Advisor
| Treatment of pulmonary embolism initially focuses on relieving symptoms of the attack with a combination of oxygen, blood-thinning drugs (anticoagulants), morphine, and fluids. Anticoagulants can be used as a preventive measure but not a cure. They should not be used on individuals susceptible to bleeding due to other medical conditions such as esophageal varices, ulcers, and liver or kidney disease. If the individual remains in critical condition following the embolism and has not responded well to emergency measures, blood clot dissolving medications (thrombolytics) may be used.
Surgical removal of the embolus (pulmonary embolectomy) is an emergency procedure done as a last resort. Surgical ligation of the inferior vena cava (vena cava interruption) or insertion of an umbrella device into the inferior vena cava (blocks blood clots from traveling to the lungs) is considered when recurrence of the disease is life-threatening in cases where the individual cannot tolerate anticoagulant therapy or has septic thrombophlebitis of pelvic origin.
Comparative outcomes of pulmonary embolectomy and anticoagulation (with either thrombolytics or heparin) have not been extensively studied. Surgical interruption of the vena cava does not necessarily prevent subsequent embolism. Insertion of an umbrella device or filter effectively reduces the incidence of pulmonary emboli but is associated with increased risk of recurrent deep vein blood clots in the lower extremities. Evidence of recurrent pulmonary embolism is reported in 2% to 4% of individuals after filter insertion (Putnam). Thrombolytic therapy is associated with an increased risk of intracranial hemorrhage at a rate of 1% to 2% and hemorrhage at traumatic or surgical sites (Goldhaber). Surgical embolectomy, which requires cardiopulmonary bypass, is associated with mortality rates as high as 11% (Kumar). Mortality and morbidity are greatest in those with a history of cardiac arrest or pre-existing cardiovascular disease. |
Source: Medical Disability Advisor
| Prognosis depends on the underlying disease and proper diagnosis and treatment. The outcome for survival is good. After diagnosis and treatment, recurrence is 17% due to recurrent blood clots in the legs (Sharma). Death from recurrent emboli is less than 5% for those treated with anticoagulants. Approximately 0.1% of individuals develop elevated circulatory pressure in the lungs secondary to persistent pulmonary emboli (chronic thromboembolic pulmonary hypertension) (Fedullo). This can result in serious heart and lung problems or cause early death. |
Source: Medical Disability Advisor
| Rehabilitation of a pulmonary embolism begins once the origin and reason for the blood clot is identified (i.e., surgery, trauma, or childbirth) and the situation stabilized. The extent of rehabilitation will depend on the amount of damage resulting from the blood clot and whether surgery was required to remove the embolus. Early rehabilitative exercises are critical in preventing further emboli since blood clots in the leg veins are particularly common after any operation. Exercises may include activities such as walking. If walking is not an option, the physical therapist or other rehabilitation professional may assign leg exercises to reduce the risk of clot formation.
Rehabilitation is more involved if the individual must regain strength following surgical removal of the pulmonary embolus. Early rehabilitation primarily focuses on preventing any breathing difficulties and regaining upper extremity range of motion that may have been lost due to surgery on the chest muscles. Early in the program while the individual is still hospitalized, the rehabilitation professional may assign breathing and relaxation exercises. These strategies reduce oxygen demand by decreasing the work of breathing and reducing accessory breathing movements. To allow the individual to slowly adjust to the increase in oxygen demand, exercise sessions begin with a prolonged warm-up.
A physical therapist experienced in cardiac and pulmonary rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. As the individual progresses with breathing and relaxation techniques, active assist range of motion exercises to the upper and lower extremities begin. As the individual's endurance increases, the next step of progression is active range of motion in which the individual performs all motion independently. As endurance continues to improve without shortness of breath, active upper and lower extremity exercises are initiated that use very light resistance in addition to light aerobic activities such as brisk walking or low-resistance biking. The individual will progress to increased activities and exercises that simulate work. The goal is to increase strength, decrease symptoms, and increase endurance so the individual will be more active and eventually return to work.
Rehabilitating from a pulmonary embolus may be a lengthy process in order to obtain the maximum benefit of increased pulmonary stamina and prevention of future clotting. Because most individuals with pulmonary disorders are managed with medication, it is important that rehabilitation personnel know what these medications are since many of these drugs alter the acute and chronic response to exercise. Treatment with blood-thinning (anticoagulant) medications is usually continued for an average of 6 months following the episode. Anticoagulation medications increase the risk of bleeding, therefore, precautions should be taken to avoid tasks with a risk of physical trauma that may precipitate bleeding. |
Source: Medical Disability Advisor
| Complications include lung collapse (atelectasis), pulmonary hypertension, shock due to low cardiac output, cardiopulmonary arrest, abnormal heart rhythms (arrhythmias), very low oxygen levels (hypoxemia), infection, and lung infarction. |
Source: Medical Disability Advisor
| Since pulmonary embolism is a result of a blood clot typically originating in the veins of the legs, it is vital for a predisposed individual to avoid sitting for prolonged periods of time. If long automobile or plane trips are a part of employment, the individual should take periodic breaks from sitting to restore circulation.
The major concern while on anticoagulation is the increased risk of bleeding; therefore, the individual should avoid high-risk tasks such as heavy labor that may precipitate bleeding or tasks that may cause falls. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have chest pain with shortness of breath, cough, and coughing of blood? Is individual cyanotic?
-
Does individual have risk factors such as prolonged bed rest or inactivity, surgery, femur or pelvic trauma, central vein catheters, cancer, endocarditis, childbirth, stroke, congestive heart failure, frequent air travel, or obesity?
-
Does individual have a proximal deep vein thrombosis?
-
On exam did individual have a rapid pulse, chest pain, breathlessness, and fainting?
-
Did individual have a low-grade fever, cyanosis, abnormal lung sounds, and wheezing? Does the individual have cold, clammy skin, weak pulse, and low blood pressure?
-
Has individual had a chest x-ray, electrocardiogram, lung scan, and arterial blood gases? Did individual have a pulmonary angiogram, CT scan or MRI?
-
Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Is individual being treated with oxygen, anticoagulants, morphine, and fluids?
-
Was it necessary to use thrombolytics?
-
Did it become necessary to perform surgery?
Regarding prognosis:
- Is individual's employer able to accommodate any necessary restrictions?
-
Does individual have any conditions that may affect ability to recover?
-
Does individual have any complications such as atelectasis, pulmonary hypertension, shock due to low cardiac output, cardiopulmonary arrest, infection, or lung infarction?
|
Source: Medical Disability Advisor
| Dalen, J. E. "Pulmonary Embolism: What Have We Learned Since Virchow? Natural History, Pathophysiology, and Diagnosis." Chest 122 4 (2002): 1440-1456. Chest. Oct. 2002. American College of Chest Physicians. 1 Nov. 2006 <http://www.chestjournal.org/cgi/content/full/122/4/1440>.Fedullo, P. F. "Pulmonary Thromboembolism." Textbook of Respiratory Medicine. Eds. Jay Murray and John F. Nadel. 3rd ed. Philadelphia: W.B. Saunders, 2000. MD Consult. Elsevier, Inc. 7 Jan. 2005 <http://home.mdconsult.com/das/book/39617026-2/view/919?sid=288478385>. Goldhaber, S. Z. "Pulmonary Embolism." Heart Disease: A Textbook of Cardiovascular Medicine. Eds. E. Braunwald, et al. 6th ed. Philadelphia: W.B. Saunders, 2001. MD Consult. Elsevier, Inc. 7 Jan. 2005 <http://home.mdconsult.com/das/book/39617026-2/view/924?sid=288474955>. Kumar, S. R. "The Vasculopathic Patient: Uncommon Surgical Emergencies." Emergency Medical Clinics of North America 21 4 (2003): 803-815. MD Consult. Elsevier, Inc. 7 Jan. 2005 <http://home.mdconsult.com/das/journal/view/39617026-2/N/14247202?sid=288476801&source=MI>. Putnam, J. B. "Lung/Pulmonary Embolism." Sabiston Textbook of Surgery. Eds. C. M. Townsend and D. C. Sabiston. 16th ed. Philadelphia: W.B. Saunders, 2001. Sharma, Sat. "Pulmonary Embolism." eMedicine. Eds. Gregory Tino, et al. 10 Nov. 2004. Medscape. 7 Jan. 2005 <http://emedicine.com/med/topic1958.htm>. |
Source: Medical Disability Advisor
| Feedback |
| Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must
include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment.
If you are seeking medical advice, please contact your physician. Thank you! |
Send this comment to:
Sales
Customer Support
Content Development
|
|
| |
|
|
|
|
|
This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is published with the understanding that
the author, editors, and publisher are not engaged in rendering medical, legal,
accounting or other professional service. If medical, legal, or other expert assistance
is required, the service of a competent professional should be sought. We are unable to respond to requests for advice.
Any Sales inquiries should include an email address or other means of
communication.
|