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February 10, 2012

Pulmonary Embolism (cont.)

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What are the signs and symptoms of pulmonary embolism?

A pulmonary embolus may present with the sudden onset of chest pain and shortness of breath. The pain is classically sharp and worsens when taking a deep breath, often called pleuritic pain or pleurisy. There may be cough that produces bloody sputum.

The patient may have stable vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation) but frequently presents with an elevated heart rate. A severe pulmonary embolus can present with shock (low blood pressure) or cardiac arrest, particularly when a large clot blocks the outflow of blood from the right side of the heart to the lungs (saddle embolus). Depending on the amount of blood clot (clot burden or clot load), oxygen saturation can be variably compromised as can the blood pressure and heart rate. In a classic presentation, the heart rate and respiratory rate are elevated as the body tries to compensate.

Oxygen saturation may be decreased (red blood cells that do not have oxygen molecules attached to them). Oxygen saturation in a healthy individual approaches 100% at sea level.

The patient may be cyanotic (a blue tinged discoloration of the skin caused by red blood cells without oxygen), lightheaded, and weak.

In some cases, pulmonary embolus will present with sudden death, where the patient collapses, stops breathing, and their heart stops beating (cardiac arrest).

How is pulmonary embolism diagnosed?

History and physical examination

There always needs to be a high a level of suspicion that a pulmonary embolus may be the cause of chest pain or shortness of breath. The healthcare provider will take a history of the type of chest pain, including its onset and associated symptoms that may direct the diagnosis to pulmonary embolism. It may include asking about risk factors for deep vein thrombosis.

Physical examination will concentrate initially on the heart and lungs, since chest pain and shortness of breath may also be the presenting complaints for heart attack, pneumonia, pneumothorax (collapsed lung), and dissection of an aortic aneurysm, among others.

With pulmonary embolism, the chest examination is often normal, but if there is some associated inflammation on the surface of the lung (the pleura), a rub may be heard (pleura inflammation may cause friction which can be heard with a stethoscope). The surfaces of the lung and the inside of the chest wall are covered by a membrane (the pleura) that is full of nerve endings. When the pleura becomes inflamed, as can occur in pulmonary embolus, a sharp pain can result that is worsened by breathing, so-called pleurisy or pleuritic chest pain.

The physical examination may include looking for signs of a deep vein thrombosis in an extremity:

  • warmth,

  • swelling,

  • redness, and

  • tenderness.

It is important to note, however, that the signs associated with deep vein thrombosis may be completely absent even in the presence of a clot. Again, risk factors for clotting must be taken into consideration when making an assessment.


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