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What is pulmonary embolism?
occlusion of the pulmonary vascular bed
What causes pulm embolisms?
- tissue fragments
What is Vichow triad and what are they?
- venous stasis
- vascular injury
- they are risk factors for the development of thromboemoblus
Where do the majority(90%) of pulm emboli come from?
The veins of the legs and the pelvis
What are the grades of PE?
- 1 massive occlusion
- 2 embolism with infarction
- 3 embolism without infarction
- 4 multiple PE
What is a massive pulm embolism?
occlusion of a major portion of the pulm circulation (main pulmonary artery)
What is an embolism with infarction?
an embolism that is large enough to cause infarction of a portion of lungs
what is an embolism without infarction?
doesn't cause permanent tissue damage
What pathophysiological effects can an infarct have on the lungs?
- hypoxic vasoconstriction
- decreased surfactant
- release of neurohormonal substances (stress response)
- pulmonary edema b/c of loss of surfactant
- atalectasis b/c of loss of surfactant
What s/s would we see with a PE?
- chest pain
- increased dead space
- V/Q imbalance
- decreased PaO2
- pulmonary infarction
- pulmonary HTN
- < CO
What does a V/Q scan show?
ventilation and perfusion to the lungs
how would ABG's reflect PE?
- unexplained hypoxemia and hyperventilation
- CO2 may be normal or decreased (alveolar collapse)
Are chest Xrays and PFT's helpful in the diagnosis of PE?
What two exams are definitive for PE?
What is the best treatment for PE?
- prophylaxis by:
- early and often ambulation
- low dose anticoagulant therapy
- Ted hose
During what type of PE would we see streptokinase used?
massive, life threatening
What manifestations might we see for PE while our pt's are under anesthesia?
- Unexplained arterial hypoxemia
- Bronchospasm (b/c tissue damage to the lung=release of cytokines and histamine)
Will there by a widening gradient between ETCO2 and PaCO2 with PE?
yes because PE=dead space
A large unexplained drop in ETCO2 indicates what?
sudden increase in dead space (PE)
What is the normal gradient for ETCO2 and PaCO2?
5 or less
What is pulm HTN?
- a rise in pulm pressure of 5 mmHg above normal
- mean normal is 15-17
What is primary pulm HTN?
In primary hypertension the small pulmonary arteries (arterioles) become narrow or obliterated as a result of hypertrophy of smooth muscle in the vessel walls and formation of fibrous lesions around the vessels.
What is cor pulmonale?
Right ventricular disease resulting from pulmonary hypertension
What is secondary pulm HTN?
- any respiratory or cardiovascular disorder that:
- -Increases the volume or pressure of blood entering the pulmonary arteries or
- -Narrows or obstructs the pulmonary arteries
What is an example of secondary pulm HTN?
lung disease and the chronic hypoxemia that it is associated with it cause extreme HPV
What are the four causes of secondary pulmonary HTN?
- elevated left ventricular filling pressures
- increased blood flow through the pulmonary circulation
- obliteration or destruction of the vascular bed (PE, Emphysema)
- Vasoconsrtiction of the vascular beds (hypoxemia, acidosis, or both
Why do the smooth muscles in the vascular bed hypertrophy?
in response to increased pressures form pathological conditions
Is the smooth muscle hypertrophy associated with pulm HTN reversible?
no this leads to chronic pul HTN
What end organ changes does chronic pulm HTN lead to?
- cor pulmonale
- right sided HF
What meds are available to help with pulmonary HTN?
- sildafenil (viagra)
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