Pulmonary Embolism (cont.)
Venous Doppler study
Ultrasound of the legs, also known as
venous Doppler studies, may be used to
look for blood clots in the legs of a patient suspected of having a pulmonary
embolus. If a deep vein thrombosis exists, it can be inferred that chest pain and shortness of
breath may be due to a pulmonary embolism.
Echocardiography (EKG, ECG)
Echocardiography or ultrasound of the heart may be helpful if it shows that
there is strain on the right side of the heart.
If non-invasive tests are negative and the healthcare provider still has
significant concerns, then the healthcare provider and the patient need to discuss the
benefits and risks of treatment versus invasive testing like angiography.
What is the treatment for pulmonary embolism?
The best treatment for a pulmonary embolus is prevention. Minimizing the risk
of deep vein thrombosis is key in preventing a potentially fatal illness.
The initial decision is whether the patient requires hospitalization. Recent
studies suggest that those patients with a small pulmonary embolus, who are
hemodynamically, stable (normal vital signs) and who can be compliant with
treatment, may be treated at home with close outpatient care.
Those who are unstable need to be admitted to the hospital.
Anticoagulation
The first step in stable patients with pulmonary embolism is anticoagulation. This is a two
step process. Warfarin (Coumadin) is the drug of choice for anti-coagulation. It
is taken by mouth beginning immediately upon the diagnosis of pulmonary embolism, but may take
up to week for the blood to be appropriately thinned or anticoagulated. As an
immediate solution and as a bridge until the Coumadin becomes effective, low
molecular weight heparin [enoxaparin
(Lovenox)] is administered at the same
time. It thins the blood via a different mechanism. Enoxaparin injections can be
administered as an outpatient.
It is also essential to realize that warfarin (Coumadin) is in the same family of
chemicals as rat poison. Rats eat this chemical and bleed to death internally. A
clever clinician recognized that if this process was carefully monitored, this
medication could be used therapeutically to treat clotting disorders. It is
imperative that anyone taking Coumadin be carefully monitored with blood tests
and that this medication (as with all medication) be kept in a safe place.
For those patients who have contraindications to the use of enoxaparin
(Lovenox) (for
example, kidney failure does not allow the drug to be metabolized), intravenous
heparin can be used as the first step. This requires admission to the hospital
and careful patient monitoring with blood tests.
Anticoagulation is usually suggested for a minimum of six months, but each
patient will have their treatment regimen individualized. The blood test
utilized to monitor warfarin therapy is referred to as the
prothrombin time or
PT. This test can be performed by finger stick or venous stick depending on the
laboratory procedures. Since different reagents are used to measure the
prothrombin time, a ratio has been
developed for comparison of this test between different labs. It is referred to
as the International Normalized Ratio or INR. Usually, for these clotting
conditions, your physician will want you to take enough warfarin to keep your
INR between two and three. It is very helpful for the patient to participate in their
health management by keeping a diary of their warfarin dose, the date of testing, and
their INR values.
Next: Thrombolytic therapy »
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