1. Pulmonary Embolism Aortic Aneurysm Aortic Dissection Nursing 313, Fall 2011

2. Incidence  >650,000 cases diagnosed per year in US  Third most common cause of death in hospitalized patients  Greatest risk those who have a DVT  Recent trends: men > women  Risk doubles every ten years after 60 2

3. Risk Factors http://www.cholesterolcholestrol.com/virchows-triad.jpg 3

4. Pathophysiology Clot lodges in PA or branches ↑ in Dead Space → VQ Mismatch ↑ PA Pressures ↑ in Vaso & Bronchoconstriction ↑ RV workload → RV Failure Release of Vasoactive Substances 4

5. Respiratory System  A balancing act between ventilation (V) and perfusion (Q) 5

6. Perfusion / ventilation mismatch V/Q mismatch  Obstructed area has absent or diminished blood flow  Alveoli ventilated but not perfused which causes increased dead space  Severity depends on size of embolism and degree of vascular obstruction  Possibility of severe hypotension and shock 6

7. Pulmonary Embolism 7

8. Signs and Symptoms  Sudden onset of dyspnea  Sudden onset of pleuritic chest pain  General signs of hypoxemia  Feeling of impending doom  ↑ Anxiety  Cough, possible hemoptysis  Mild fever  Diaphoresis 8

9. If severe, then cardiac involvement  Cardiac s/s are due to loss of the forward flow of blood JVD S3 or S4 Syncope Tachycardia Tachypnea Rales Signs of right sided heart failure 9

10. Diagnosis  D-Dimer assay – possible method of ruling out a PE  Spiral CT scan  Pulmonary Angiography (gold standard)  V/Q scan  CXR, ECG, ABGs 10

11. Emergency Management  Stabilize the cardiopulmonary system Oxygen Insertions of IV lines Treat hypotension – vasoactive drugs if ↓BP Diagnostic testing: scans, ABGs, labs Indwelling urinary catheter Sedatives or pain relief as needed Prevent further emboli from forming 11

12. Pharmacological Management Heparin  Heparin- initial and preferred treatment  Does not affect the existing clot  PTT/ therapeutic range 1.5 to 2 times normal  Antidote: protamine sulfate 12

13. Warfarin  Warfarin (Coumadin)  Interferes with the synthesis of the vitamin K  3-4 days for therapeutic benefit  INR between 2.0 – 2.5 for those with PE  Antidote – Vitamin K 13

14. Thrombolytic Therapy  tPA, Alteplase, Reteplase  Converts plasminogen to plasmin  Specific contraindications: Recent CVA; active bleeding; surgery in past 10 days; trauma; recent labor and delivery, severe hypertension  Major complication: bleeding 14

15. Nursing Management of Patients on Anticoagulation Therapy  Frequent vital signs  Hematest stools  Handle patient gently  Avoid IM injections & veni-punctures  Use electric shaver & soft toothbrushes  Nothing per rectum  Avoid foods containing vitamin K  Monitor labs 15

16. Surgical Management  Thrombectomy or Embolectomy  Vena Cava Interruption (Filters) Indicated in patients who may not tolerate anticoagulation 16

17. Greenfield Filter 17

18. Nursing Management  Identify patients at risk  Manage pain!  Psychosocial support for patient and family  Utilize nursing interventions to minimize risk Early ambulation  Watch labs, VS, targeted assessments for cardiopulmonary system  Patient & family teaching on importance of lifestyle changes 18

19. 19

20. Aortic Aneurysms 20

21. Flash from the past…. 21

22. Factoids  Atherosclerosis damages the lining of the aorta  Majority below the renal arteries  Exact cause of aneurysm unknown  More common in Caucasians  More common in men than women Higher risk of rupture and death in women compared with men with same size aneurysms  Rare in young females, but related to pregnancy 22

23. Incidence & Risk Factors  13 th leading cause of death in men aged 65-75  Up to 13% of individuals with AA have multiple aneurysms  Causes about 9,000 deaths / year  Risk factors: Atherosclerosis Patients born with bicuspid aortic valves (new) Hypertension Age Smoking,  cholesterol, ↑lipids Genetic CT disorders (Marfan’s) History of crack use in pregnancy Positive family history  Often found incidentally 23

24. Classification: Morphology 24

25.  Abdominal More common (75%) Usually infra-renal  Thoracic Less common (25%) > chance of rupture & dissection Classification: Location 25

26. Clinical Manifestations  Abdominal Aortic Aneurysms Asymptomatic (early) Symptoms caused by expansion (later)  Chest or abdominal pain, flank pain, scrotal pain  Pulsatile mass palpated (80%), bruit +  Feels like heart beating in abdomen Ruptured aneurysm is a medical emergency 26

27. Thoracic Aortic Aneurysms  Asymptomatic (early)  Symptoms by compression of tissue (later) Ascending: CHF due to aortic regurgitation, edema of the UE and face Arch or descending: wheeze, cough, hemoptysis, dysphagia, hoarseness Chest or back pain is common to both Clinical Manifestations 27

28. Aortic Aneurysm Rupture 28

29. Aortic Dissection  Occurs when there is a tear in the intimal lining (or adventitia) and blood gets diverted into the channel → ↓ intravascular volume  http://www.youtube.com/watch?v=ZtanUq95 pTk http://www.youtube.com/watch?v=ZtanUq95 pTk 29

30.  More common in thoracic aneurysms  May interfere with major aortic branches causing organ failure  Classification system: Debakey Debakey Stanford Stanford  Clinical manifestation: PAIN!!!! 30

31. Aortic Dissection Classifications  DeBakey Classification:  Type I - originated in ascending aorta  Type II - originated in and is confined to ascending aorta  Type III - originated in descending aorta  Stanford Classification  A - Originated and involves ascending aorta.  B - Originated and involves descending aorta 31

32. Dx tests for Aortic Dissections  Trans thoracic echocardiogram (TTE)  Trans esophageal echocardiogram (TEE)  Computed Tomography Angiography (CTA)  Magnetic Resonance Angiography  Ultrasonography  Aortography 32

33. Medical Management of Aortic Aneurysm  Control /eliminate risk factors  F/U every 3 to 6 months (ultrasounds)  Medications Beta-blockers/calcium channel agents (older) Recent evidence favors ACE inhibitors over BB Statins, Doxycycline: both inhibit matrix metalloproteinases (MMPS)  MMPs are enzymes that break down elastin and collagen in the aortic wall – contributes to aneurysm formation 33

34. General Indications for Surgical Repair of Aortic Aneurysms  Diameter ≥5.5 cm (men)  For women, 4.5-5.0 cm (due to greater incidence of rupture)  Ascending Thoracic  Diameter ≥5.5 cm (5 cm in patients with Marfan syndrome)  Symptoms suggesting expansion or compression of surrounding structures  Rapidly expanding aneurysms (growth rate >0.5 cm over a 6-month period)  Symptomatic aneurysm 34

35. http://www.cvtsa.com/ListofConditions/A-444-62.html 35

36. Open Aneurysmectomy 36

37. Endovascular Stent Grafts (EVSG) 37

38. EVAR  60% of aneurysm repairs in the US  Fewer immediate complications than conventional surgery  More interventions are needed after 2 years with EVAR (graft leaks, graft migration or infection, bowel perforation, etc)  Similar survival rates at 6 years (EVAR vs. open) 38

39. Post op care of surgical repair of AAA  Post op complications MI Cerebral infarct or ischemia to spinal cord Hypovolemia Respiratory distress Paralytic ileus Renal Failure 39

40. Postoperative nursing management  Cardiovascular Monitor for dysrhythmias Control of BP Monitor labs  Renal Hourly urines Monitor renal indicators 40

41. Postoperative nursing management  Respiratory Prevention of complications Meticulous pulmonary hygiene Control pain  Gastrointestinal Assess motility  NGT for suctioning (ileus) Monitor girth Provide nutrition Administer antibiotics 41

42. Postoperative nursing management  Neurological Neurovascular checks  Graft Occlusion or Rupture Assess for changes in pulses; temperature & color of extremities; severe pain Abdominal distention Decreased urine output  Post endovascular stent procedure complications 42

43. 43