Are you missing patients with pulmonary embolism?
If a patient came to your ED complaining of fever, anxiety, or coughing, would you suspect a pulmonary embolism? When 39-year-old NBC News reporter David Bloom died in April of a pulmonary embolism while covering the war in Iraq, a spotlight was put on this condition, with which 600,000 patients are diagnosed each year.1
Patients with pulmonary embolism often slip through the cracks in the ED, precisely because the symptoms are so vague, says Marla Gain, RN, BS, MICN, clinical educator for emergency services at University of California — Irvine Medical Center in Orange. "Many pulmonary embolisms are missed completely or misdiagnosed initially in the ED," she says.
A 2003 clinical policy from the Dallas-based American College of Emergency Physicians gives new recommendations for patients with pulmonary embolism.2
"You’ll be seeing changes in diagnostic testing protocols and administration of fibrinolytic therapy to specific patients," says Julie Bracken, RN, MS, CEN, associate director of nursing staff development for University of Illinois Medical Center and former director of nursing education at Cook County Hospital, both based in Chicago.
To dramatically improve care of patients with pulmonary embolism, do the following:
• Look for nonspecific symptoms.
Have a high index of suspicion, as patients may not present in a way that you expect them to, warns Gain, pointing to a recent case of a 35-year-old man who had a deep vein thrombosis with very mild shortness of breath.
"They decided to do a spiral CT [computed tomography], and lo and behold, he had an extensive pulmonary embolism," she says. "He had a very positive outcome without deficits."
Nonspecific symptoms may include chest pain, shortness of breath, anxiety, cough, sweating, and syncope, says Gain. "ED nurses need to keep a high level of suspicion secondary to risk factors, such as deep vein thrombosis, bed rest, long trips, surgeries, cancer, birth control pills, and pregnancy," she says.
Since you are the primary collector of history and assessment data, you must carefully assess symptoms and signs of deep vein thrombosis and pulmonary embolism, says Bracken. "This leads to quicker suspicion, work-up, diagnosis, and treatment," she stresses.
You may not pinpoint the actual diagnosis in triage, but the goal should be to determine the patient’s acuity so he or she can be seen in a timely and appropriate order, says Gain. "You need to look at the complete, subtle picture the patient is painting," she advises. "At times, your antenna should be raised for patients with nonspecific complaints."
The patient’s lung sounds may be clear bilaterally, and oxygen saturation levels can be more than 95%, notes Gain. "They may be mildly tachycardic, anxious, or have a fever, but again, these are nonspecific," she says. "Unless the patient is in extremis and has a huge pulmonary embolism, physical findings are nonspecific — just like their complaints."
• Stay current with cutting-edge diagnostic testing.
Diagnostic tests for pulmonary embolism include D-dimer marker tests, whole blood cell tests, ventilation-perfusion (VQ) lung scan, and CT scan, says Bracken.
D-dimer marker tests consist of five types: enzyme-linked immunosorbent assay, latex agglutination assay, whole blood assay, turbidimetric assay, and immunofiltration assay, says Bracken. Immunofiltration assay can be performed at the bedside, similar to urine pregnancy, notes Bracken. "This potentially could be delegated to the ED nurse," she says.
Currently, the V/Q lung scan is the most frequently ordered diagnostic test for pulmonary embolism, says Bracken. "You can expect this test to continue to be the most often ordered, except now it may be combined with venous ultrasound and/or D-dimers in low-to-moderate pretest pulmonary embolism probability patients," she notes.
Spiral CT studies have shown increased identification of pulmonary embolism, says Bracken. "This test should gain in popularity," she predicts.
All patients who come to the ED with suspected pulmonary embolism are closely monitored and transported on a cardiac monitor with an intravenous line, oxygen, and pulse oximetry, says Gain. Once the electrocardiogram and chest X-rays are completed, arterial blood gas and D-dimers are drawn and sent, she says.
Arteriograms are the gold standard, says Gain. "These can be considered definitive. However, these are not commonly used," she says. "This is because they are invasive, they are not timely, they’re costly, and patients must have good renal function."
Treatment consists of aspirin, low molecular weight heparin or intravenous heparin, and tissue plasminogen activator for patients in acute crisis, says Gain. "They will hopefully be discharged home after a few days on [warfarin]."
• Assess the patient’s response to treatment.
According to clinical trials and consensus reports, fibrinolytic agents are useful only in treating patients with hemodynamic unstability, especially with persistent systemic hypotension, says Bracken. "Therefore, you must constantly assess the patient’s response to treatment in this difficult population," she advises.
Because fibrinolytic agents are given to patients with systemic hypotension, there is a danger of missing side effects of internal bleeding, Bracken explains.
These symptoms include shortness of breath, tachypnea or tachycardia, sudden onset of pleuritic chest discomfort, cough, diaphorsis, syncope, crackles, new onset right-bundle branch block on electrocardiogram, and arterial blood gas changes with a drop in oxygen pressure and partial pressure of carbon dioxide, says Bracken.
"The symptoms usually recognized for internal bleeding are the same as those for systemic hypotension," she says. "Diligence is required to monitor for this side effect of fibrinolytic therapy."
References
1. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism: A statement for health care professionals from the council on thrombosis (in consultation with the council on cardiovascular radiology), American Heart Association. Circulation 1996; 93:2,212-2,245.
2. American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism. Ann Emerg Med 3003; 41:257-270.
Sources
For more information about pulmonary embolism, contact:
• Julie Bracken, RN, MS, CEN, Associate Director, Nursing Staff Development, University of Illinois Medical Center, 1740 W. Taylor St., Chicago, IL 60612. Telephone: (312) 996-9267. Fax: (312) 996-0630. E-mail: [email protected].
• Marla Gain, RN, BS, MICN, Clinical Educator, Emergency Services, UCI Medical Center, 101 The City Drive, Orange, CA 92868. Telephone: (714) 456-5675. Fax: (714) 456-5390. E-mail: [email protected].
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