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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 Describe diagnostic tests for pulmonary embolism Verbalize interventions used to treat massive pulmonary embolism and subsequent strategies to optimize patient outcomes Describe the implications of utilizing new technologies during CPR that may lead to positive outcomes

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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. 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 The Joint Commission has established guidelines for VTE prophylaxis for this specific reason

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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 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

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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

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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 Heparin and antibiotics initiated Central line placed Intubation performed per anesthesia Levophed initiated

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AdmissionPre IntubationPost Intubation pH7.217.097.19 pCO2537361 CO2232425 BE-7-8-5 pO24555115 O2 sat707497 HCO3212223

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Emergent Cardiology consult ECHO revealed pulmonary hypertension and right ventricle dilation suspicious for pulmonary embolism (PE) Chest CT (angio) Bilateral PE

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Anticoagulation Thrombolytics IVC Filter Embolectomy

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Reduce propagation of existing clot Prevention of new clot formation or embolization Adverse effects: bleeding, HIT

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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 Recurrent VTE Hypercoagulable state Contraindications for high dose anticoagulation RELATIVE INDICATIONS 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? Key risk factors to consider?

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Systemic lytic therapy was initiated following consult with a neurosurgeon 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 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. 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

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Agitation and hypertension Worsening neck/facial swelling Neck hematoma discovered Bronch revealed partially obstructed ETT To OR for evacuation

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Hemodialysis started 2 L off Ventilator weaned to CPAP Day 14 - Trach placed Day 23- Transferred to the step down unit

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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 High quality CPR utilizing technology Understanding of interventions for massive pulmonary embolism Management strategies for post arrest pulmonary embolism patients

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Agnelli, G. and Becattini, C. (2010) Acute pulmonary embolism. New England Journal of Medicine 363(3) pp. 266-274. Andrews, P. and Habashi, N. (2010). Detecting, managing and preventing pulmonary embolism. American Nurse Today 5(9) pp. 21-26. Belchlavek, J., Dytrych, V. and Linhart, A. (2013) Pulmonary mbolism, part 1: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Experimental and Clinical Cardiology 18(2) pp. 129- 138. Bonnemeyer, H., Simonis, G.,Olivercrona, G., Werdtmann, B., Gotberg, M., Weitz, G.,Gering, I., Strasser, R., Frey, N. (2011). Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity. Resuscitation 82(2) pp. 155-159. Carr, M. and Muller, C. (2011).Treatment of a massive pulmonary embolism in a soldier in Kosovo: the potential value of cardiopulmonary resuscitation and fibrinolytic therapy Military Medicine 176(12) pp. 1453-1456. Fox, J., Fiechter, R., Gerstl, P., Url, A., Wagner, H., Lscher, T. F., &... Wyss, C. A. (2013). Mechanical versus manual chest compression CPR under ground ambulance transport conditions. Acute Cardiac Care, 15(1), 1-6. doi:10.3109/17482941.2012.735675

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Lang, E. (2014). In out-of-hospital cardiac arrest, mechanical CPR did not improve survival compared with manual CPR. Annals Of Internal Medicine, 160(4), JC5. doi:10.7326/0003- 4819-160-4-201402180-02005 Leong, S. (2011). Mechanical CPR. Singapore Medical Journal 52(8) pp. 592-594. Piacentini, A., Volonte', M., Rigamonti, M., Guastella, E., & Landriscina, M. (2012). Successful Prolonged Mechanical CPR in a Severely Poisoned Hypothermic Patient: A Case Report. Case Reports In Emergency Medicine, 2012381798. doi:10.1155/2012/381798 Tapson, V. (2010). Acute pulmonary embolism. New England Journal of Medicine 358(10) pp. 1037-1052. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107 [23 suppl 1]:I4-I8.