Pulmonary Embolism Explained Clearly – Risk factors, Pathophysiology, DVT, Treatment

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /

okay well welcome to another MedCram
lecture today we’re going to talk about pulmonary embolism and specifically
we’re going to talk about the epidemiology and also the risk factors in the next lectures we’ll talk about
other things for instance the diagnosis and treatment but let’s talk about
pulmonary embolism its epidemiology risk factors things of that nature first of
all what is a pulmonary embolism well to look at this we’ve got to look at the
relationship between the heart and the lungs as we know we’ve got the heart
which pumps blood to the lungs and also the left side which pumps blood to the
rest of the body and in each side we’ve got the lungs which sits on the
left and the right now of course we know that the venous system not only from the
bottom but also from the top drains into the right side of the heart and from
there from the right atrium it goes to the right ventricle and the right
ventricle pumps blood specifically to the lungs because of this any blood clot
in any vein is eventually going to end its way up if it breaks forth into the
right side now because of that the right side of the heart pumps this clot into
the pulmonary arteries and because the pulmonary artery gets smaller and
smaller and smaller and smaller that blood clot is going to get caught
in the lungs and get lodged and that’s what’s known as a pulmonary embolism now
typically because blood flow typically goes more to the lower part of the lung
than it does the upper part of the lung and that’s a result of gravity more or
less because of this you’re going to see more
pulmonary embolisms in the lower portion of the lungs and less in the upper of
course it can happen anywhere but just as a general rule since more blood flow
goes to the lower portion of the lungs you’re going to tend to see more blood
clots lodging in the lower portion of the lungs now is there any predilection
as to what side they tend to go on now the answer is not really but it’s
possible for it to actually get stuck in the middle where the pulmonary artery
branches that’s known as a saddle embolus and that can be fatal obviously
because of the large amount of blood flow that gets disturbed and that type
of pulmonary embolism okay so what is the incidence of pulmonary embolism
believe it or not it’s about 600,000 people per year get a pulmonary embolism
and this results in anywhere between 50,000 and 200,000 deaths per year
that’s a lot of people and so I think this is an important diagnosis to talk
about okay now that you know what they are let’s talk a little bit about them
in general first of all we miss them a lot what do I mean by that we miss them
a lot they happen a lot in the emergency room and in the hospital and we fail to
pick them up because we don’t realize this and how do we know that we miss
them a lot because of autopsies okay we see them on autopsies and we didn’t even
think that the patient would have had them we also test for these a lot and what happens is they’re negative so
we think that they’re there and we test and they don’t turn out to be positive
and in other cases we don’t even think about them and on autopsy we see
pulmonary embolism what does that tell you tells you that we’re not doing a
good job of picking these things up and it’s probably one of the most
misdiagnosis in the hospital where do these things come from
well most pulmonary embolisms are from deep venous thrombosis and most
pulmonary embolisms from deep venous thrombosis come from the lower
extremities above the knee so they’re in the legs above the knee that’s where we
need to start looking for these things so well what is the pathophysiology the
pathophysiology specifically is is that these blood clots form down in the legs
because of a number of possible risk factors they break off they go up the
inferior vena cava to the right atrium to the right ventricle and then they
lodge themselves in the lungs now what happens there when the blood cut gets lodged in the
pulmonary artery there is no more perfusion to that area of the lung and
so what you’re getting there is ventilation without perfusion and that
is basically dead space and more forward is that the blood that should have gone
to that area that has to get diverted to other areas of the lung and then you get
an increased flow of blood to the other areas and so the major mechanism is VQ
mismatch if you have any questions about the mechanism of VQ mismatch please see
our hypoxia lectures and the mechanisms of hypoxemia now you also get increase
in resistance to blood flow especially on the right side specifically and that
can cause cardiac arrest in some situations you can actually get the
lungs to infarct about 10 percent of the time it’s difficult because there’s a
dual blood supply as many of you know the lungs have a dual blood supply we
know that the pulmonary artery goes to the lungs with deoxygenated blood okay so deoxygenated blood goes to the
lungs that way but also the aorta which is coming off from the left side of the
heart also sends branches over to the lung and so it’s difficult to infer the
lung completely okay so let’s talk about risk factors what are the risk factors for pulmonary
embolism now the reason why this is important as we’ll talk about later is
that there is no test for pulmonary embolism that you would order in another
situation and accidentally pick up a pulmonary embolism what do I mean by
this I mean the only way you’re ever going to make a diagnosis of a pulmonary
embolism is if you order a very specific test looking for pulmonary embolism
what does that mean that means if you’re not thinking about pulmonary embolism
you’ll never really make the diagnosis so it’s very easy to miss it so what are
the things that should clue you in that this is a pulmonary embolism well it’s
risk factors so what are some of the risk factors one it would be an ortho
pivec procedure okay so what do I mean by that we’re talking hip replacements
knee replacements or repair of fractures these sorts of procedures cause patients
to not only be laid up in bed but also the endothelial damage that occurs
during these surgeries and the fact that these patients probably haven’t been
moving around very much in the preceding days two weeks before this procedure so
if somebody has an orthopedic procedure and comes down with symptoms of
tachycardia to give me as we’ll talk about then you need to think about a
pulmonary embolism number two patients without prophylaxis what do I mean by
prophylaxis this is like DVT prophylaxis well the things that we’re thinking
about in hospitalized patients would be bilateral lower extremity sequential
compression devices or anticoagulants things like heparin lovenox warfarin
things of that nature even things during surgery so these are all possibilities
what’s another risk factor number three abdominal or pelvic surgery especially
if it’s done for cancer so cancer or abdominal pelvic surgery could increase
the risk and does increase the risk number four obesity increases the risk
number five women greater than thirty years of age and they are on OCPs
and they’re smokers this is a serious combination right here that you
shouldn’t forget I’ve seen personally in the intensive care unit in fact in one
month I saw two women over the age of thirty on oral contraceptives who were
smokers and they had problems they had pulmonary embolism so bad that in fact
they ended up on a ventilator number six hypercoagulable state okay what do I mean by this things for
instance like protein C and s deficiencies so you can have one or the
other that’s a possible risk factor another
possibility would be something like factor v leiden that’s another type of
hypercoagulable state finally the last one would be pregnancy okay so think
about these things when we are trying to think whether or not a patient may have
a pulmonary embolism because these risk factors certainly could be involved okay
what about the symptoms what will be the symptoms or the clinical findings well
the first one is a high heart rate known as tachycardia the first thing you’ll
notice is that that is very nonspecific number two is just as bad and that’s two
Kip Nia these things here are very nonspecific
and can be seen in a number of diseases like pneumonia like a myocardial
infarction for instance so you have to be specific and circumspect when you’re
looking at these because these can fit into many different categories
hemoptysis or coughing up a blood especially if there is a lung infection that’s impossible clinical finding also
signs of pulmonary hypertension so what are those types of signs
well you’d sometimes see elevated liver function tests or you would see an
increase in the sound of a p2 on auscultation you might also see signs of
right ventricular hypertrophy both on palpation and also on the EKG so these
are signs and symptoms of pulmonary embolism some of the clinical findings
join us for the next lecture when we start to talk about in terms of
pulmonary embolism the diagnostic modalities so how do we figure out
whether or not this patient really does have a pulmonary embolism it’s gonna be
an interesting discussion thanks you

100 thoughts on “Pulmonary Embolism Explained Clearly – Risk factors, Pathophysiology, DVT, Treatment

  1. My right, as patient, or your right, as observer? I've got clots in my left ventricle. And arm and leg.And spent a month coughing up clots before anaphylaxis shooed me to the ER. FactorV Leiden, hetero. CA125 [likely eye injuries, repeated, dry eye, etc but tests will tell]. Just fyi/case ref.

  2. And heart failure. I'll be 43 in a month. Athlete. Domestic violence, pars frx with sciatic arterial bleeding: lots of ways my lower left leg may have been so clot-tastic.

  3. Awesome presentations. I am not a doctor but I am a former semi-elite runner so I know my body pretty well. I am 53 and can't run anymore due to osteoarthritis in my hips and knees. Right hip is bone on bone but I am too young for hip replacement. I have been biking all summer so I was alittle surprised when I was diagnosed with Pulmonary Emblolism in both lungs, today as a matter of fact. I feel better about my condition, after watching your presentations. Thanks very much

  4. Brilliant video. Thank you. My gurlfriend was diagnosed with a PE a month ago and this explains it better than anything we were told at hospital.

  5. Thank you a lot. I'm saudi medical student. And I enjoyed the video, but I hope you explain more, like why abdominal/pelvic surgeries and cancer surgery increases the risk of PE, and why pregnancy increases the risk… Again thank you

  6. Doc, M.S.N. Student here and long time Ortho Nurse. I have always wondered- Does the actual process of surgery itself create a "more likely to clot" state? in other words, when the surgeon cuts into bone does the body say – hey lets make more clotting factors etc? Thanks so much for these awesome lectures!

  7. Thanks a lot ,very helpful video! Videos about EKG, Pneumothorax and alfa/beta/muscarin receptors  would be nice,if it is possible! Greetings from Serbia

  8. This is about PE's but with a slight introduction: I just came back from having an EKG and was told how my LBBB (Left Bundle Branch Block) was no longer there.  The Doctor said he had NEVER heard of this ever happening in is entire career.  I came home (very short of breath, but do have copd), and started searching the net for hours and could find nothing on why LBBB's just go away until I stumbled into a post graduate medical journal which did  case study on a 61 year old man who had always had an LBBB and the only time it didn't show up on an EKG was when he was in ER with a PE.  After they cleared up the PE, his LBBB was back on the EKG.  I'm going to my Doctor tomorrow, as I once had a d-dimer test that came back at 2050, yes 2050, but there were no clots – just a lot of inflammation. But, I'm not ignoring what I read tonight.  

  9. These lectures are great, you break everything down in to digestible sized pieces so that all this overwhelming stuff makes sense finally!! Thanks, this will really help me study for NP boards!!

  10. I'm a new nurse and am trying to get a handle on the "bigger picture." Your video helped me understand possible complications and specifically signs and symptoms to look for. Thank you.

  11. I waited a bit too long before going to the ER with horrid chest pain, and we found out I had clots in both lungs…and I was real close to losing my life. This stuff is noooooooooo joke! I just got out the hospital, and they really don't know what cause it, they're saying genetics!

  12. Great simple breakdown of etiology, pathogenesis, clinical manifestations ect. I would have loved to hear the risk factors broken down in term of Virchow's Triad for simplicity sake. I feel like my brain works so backwards (i.e.you say… "not providing prophylaxis" I want to hear you say, "the risk is venous stasis") 6 of one, half dozen the other I suppose 🙂  Anyway, still watching all MEDcram videos, love them!

  13. Great video but I cried. I am a Pulmonary Emboli Survivor. I was misdiagnosed with anxiety. I was 35 at the time and on birth control. All my vitals were normal. I though when I went to another ER a month later, and the bloodwork showed my blood was thick, I told the dr that my mom had 7 clots in 12 yrs and was on warfarin. They sent me for an X-ray then a CT Scan. I had a medium clot in each lung, infarction, and pleural effusions. I am a walking miracle. My ER Dr is my hero.

  14. well this was pretty good but, that's not the full clinical Picture (C/P) .
    it would be better than that if u added the acute massive pulmonary embolism C/P to the vid .

  15. Hi from Albania! Thank you very much for your videos! 🙂
    I didn't understand: 1)-why resistance is getting higher?
    2)-And what does cause death when pulmonay tromboembolia? Is it hypoxi, that lead to cardiac arrest?

  16. Thank you for sharing this, I'm going to watch pt2! I'm a long time LPN getting ready to do an RA program so this was very helpful to me. I subscribed to see more of your videos as you make them and will also share with my classmates.

  17. Great video on Pulmonary embolism! Adding to this, I wanted to ask, why are the emboli typically hemorrhagic and what exactly happens?- I am referencing to Robbins Pathology

  18. Doctor good summerized info given in the video…but can yu tell me about how to get rid from this embolism if once you are trapped by this desease…???

  19. I'm not really too interested in pulmonary embolism, but I've struggled with feeling very faint and weak whenever people discuss blood, the heart or anything like that. Desensitize myself I guess

  20. Please advise. At about 6 weeks in cast from ATR repair. I had a swelling pain in the inactive cast muscle and also I a randon location of the thigh. Walking on crutches every week before 6 I have been I have been fine after week 6 I quickly get out of breath and feel like I have flu but I dont. Can this be PE or a simple allergies. Othp doc told me to go to EDept for a cat scan but I cant afgord any morw medical bills. Thanks for any advice. No chest pain, havent fainted, not coughing blood, besides selling from surgery no swelling on calf or thigh..

  21. See the whole series at www.medcram.com along with other top quality videos including reviews in pulmonary, cardiology, infectious disease, and hematology!

  22. I'm a Pulmonary Embolism survivor 12 years ago because of protein S deficiency condition (Nobody knows I have this condition). I was in the hospital for one month without diagnosis, making my way to live. Today I need to take 7.5mg warfarin but I live with fear in this could happend again, is this a posibility?, could a patien that takes warfarin have a bloodcloth again?

  23. I'm male, was 48, and thought I had pneumonia. I spent over a month going back for x-ray after x-ray. The x-ray techs, I was told later, thought I had lung cancer. Eventually I could only walk a few feet before feeling faint and having to cling to walls and furniture. My blood pressure became very low. Finally, a blood test — I don't know what kind — indicated heart damage and sent me to an ER. I was told the tops of both lungs had died, that my pulmonary artery was filled with clots, and that I should have been dead already. The cause was a condition called APS, which was apparently part of my undiagnosed lupus. I mention this because I didn't see APS listed in the video. I've read that APS most often occurs during pregnancy, which was listed, but obviously I was not pregnant. I was given a clot-buster (TPA?) and kept in ICU for 5 days. That was eight years ago. I did eventually try to go back to work, but my lupus journey was just starting, and I am now disabled. I still take Warfarin every day, keeping my INR between 2.5 and 3.5, and that seems to prevent clots from building back up. I hope this little study adds to someone's understanding of what can happen. Sometimes it really is lupus! (and APS)

  24. My mom just passed away from a pulmonary embolism at 58 with absolutely no warning. Happened all within 45 minutes. Other than being over weight, there was no indication that it might even happen.

  25. My small clinic doctor missed my PE. I told him I felt exhausted and awful, had sharp throbbing pain on one side of my ribcage. I also told him I thought I might have a clot in my calf, and that I had just flown several hours the day before. I asked him to do an EKG, and it was normal, other than tachycardia. He palpated my leg, said there was no clot, just said it was a muscle strain and sent me home. 36 hours later I called the ambulance. By then the pain had moved to the left side, and my whole ribcage fet tight. Hospital immediately suspected PE, and did CT angiogram. I had 2 large clots in each lung, and several smaller ones. They told me I was very lucky I didn't die.

  26. I'm 16 and pretty inactive but I'm built nicely and can do exercise easily but I've been having leg pain lately could that be a clot and is it a possibility at my age?

  27. i just had a dvt/pe. the doctors sent me home thinking i had sprained my calf. i went back to the hospital the next day and they figured out what was happening. i am now on pradaxa and trying to stay positive. they have no idea why this happened. life is precious. stay strong!!!

  28. Great video! What about the MTHFR mutation, would that be a risk factor as well? being that someone with this mutation such as myself is more prone to blood clotting. I've been having sharp shooting pains where my heart is or around there anyway sometimes it'll be on the right side too and its worse if I breath in deep but it doesn't last long. I've had this issue for over a year now maybe close to 2 yrs 😞 and I get heart palpitations

  29. Great truth here! I survived many DVTs but nearly succumbed to a PE which the D Diomer did not verify. Damage to my right side of the heart …. BBBB.

  30. My father just past away yesterday morning because of this. It happened so fast within 30 mins. He was 63. I wish I watched this video before it was too late.

  31. Happened to me Jan 5th, i collapsed after only walking up 1 flight of stairs. After 10 days in CCU i'm now on 40mg of Crestor, 5 mg Warfirin, 81 mg aspirin, 5mg ramipril, and 10 mg bisoprolol x2 a day. These will change as time goes on according to dr.

  32. Leaving this comment up, but I see that you covered CT angio in part 3 of this series. My original comment: You said that you wouldn't find a PE unless you were looking specifically for them. Mine was found through a routine CT angiogram with contrast. I understand now that this is the most common method to find PEs. In my case, my heart was being studied/checked because of family history of CAD. I do not have CAD, but they found a single PE and I am on blood thinner for at least 6 months. The cause of mine is not known yet, but I just had blood tests for the various genetic causes and waiting for results. Will also have a Doppler scan of legs to check for DVTs. I did not have shortness of breath, but I'd been extremely tired for weeks.

  33. I'm hoping somehow you read this or someone does cause this is an older video.
    About a month and half ago I started really running out of breath easily and my heart was racing. I was sent to a cardiologist and I found out today all tests turned out fine. He now wants to test and see if I have a blood clot in my lungs cause I'm not really active. Is it even possible to have a blood clot for this long? He said that if nothing shows on this test then I'm just really out of shape. I know I'm not in the best shape but I don't think it's possible to be able to go up 3 flights of stairs with relatively no breathing issues and then the next day almost dying doing the same stairs let alone walking across my 750 sq foot apartment!
    I'm alittle frustrated. I was reading about this lung blood clot and it says nothing about wether you can live with a partial blockage and still be ok? Can someone help please?

  34. I just had multiple extensive pulmonary embolisms. I was first misdiagnosed with costochondritis by my pcp. I'm 33, non-smoker, and had just started using Nuvaring for BC. My only symptom was chest pain and it was severe. It hurt to breathe and,to laugh even, and the ER Dr. Promptly did a D. Dimer on me when I went in, followed by all the other tests and being admitted to ICU. I am blessed to be here still.

  35. What if there are no blood clots in the knees but only the lungs I’m asking because I have about 10 clots in my lungs but none in my knees the doctor put me on warfarin to help with the clots is it possible to have them form in the chest but not the knees

  36. Hi my mother diagnosed with PE in CT scan with a contrast. There is a thrombus in the left main pulmonary artery initially given LMWH injections for 5 day’s and then shifted to PRADExa tablets. Will this thrombus go away? how many days will it takes to dissolve thrombus. Currently there’s no signs of DVT.

  37. Thanks so much for this video. I never thought anything about blood clots until I was in a cycling accident on July 12 of this year that resulted in a pelvic fracture (thankfully stable and no surgery) and subsequent DVT in my right calf and clots in my lungs. The first sign for me was the left chest pain, 2 days later right chest pain and shortness of breath. I have been in the ER and hospital the past 2 months way too many times. The lack of information for clots has been frustrating to me. I am also an endurance athlete which I found out is another reason for blood clotting. Thanks again for the education.

  38. The most frustrating thing is that these don't show alarming symptoms in about half of cases, meaning the first symptom is either sudden death or issues breathing. So half the time you just suddenly die, and in the other quarter your only warning is that you are in the process of dying. I think this is one of those things that will continue to be a problem until there is some advancement that allows us to quickly do a full body assessment as a standard approach to every contact with a doctor.

  39. Q: How long can they be in you lungs before Dr's realise they are there? I believe they have been with me for 2 to 3 years, as I started getting strange feelings in my right leg where it would go numb and tingly when walked on, had that checked for DVT and came back clear.
    Then 6 months or so later I get aches/pain behind my left should blade but inside my body area at random, not after eating anything just at random any time, then late last year or very early this year had coughing fits and at night couldn't breath very well and went to the hospital and the young Dr I had blamed smoking and was quit nasty and nothing they could do, and prescribed some pill's, but it settled and seemed normal again but was worried with the pains I was getting and finally asked my Dr what it could be, and was told I have rheumatoid arthritis.
    Thought this must be the situation and I would have to live with it….. Then recently [Three and a half weeks ago] talking to my brother on the phone started to get bad sharp pains in my chest just behind my left breast, I really thought this is it and after about 15 minutes the pain shot straight to the spot behind my shoulder like a knife straight line, wow this was intense, got off the phone and my daughter rang hubby and then I rang the Dr's to see if my Dr was on, yes she was, but when we got there she was busy and we saw another Dr whom called an Ambulance to rush me to the Hospital where they did heaps of blood tests and found nothing, 6 hours later we were sent home pain half strength next day pain gone.
    Nearly 3 weeks later I went to get tablets for quitting smoking and asked about the results from the Hospital, and then about the blood tests, to then hear she was concerned there could be blood clot in a lung as of how high one test came up, so I went to one imaging place in town last Wednesday where they did C/T scan with in to my blood, and when finished headed home thinking all was ok, to them ringing me crazily to go to my Dr for this result Immediately. So this I did to hear yes I do have blood clots to my Lungs, and I asked if he could count them and her said there are many and he wants to save my life. :O
    The other tests were of kidneys and gore bladder, they are stone free but cyst on left kidney, but other wise all organs okay. 🙂
    Now I'm taking Xarelto to thin blood and stop clotting.
    My big question is "How long can blood clots be in your lungs before you know they are there, ?? 1 week, 1 month, or many years if it doesn't kill you first?????
    Kindly Helena

  40. Hi please I need urgent advice I have a dvt 20 yeas ago and I'm still havite left iliac all the vein 20cm blooked and have fews blood clot in my lower left leg i will have surgury in 2 weeks time for a stent in my blooked iliac large vein do this surgery increase the risk for PE? Please the cause of my dvt is the behects desease

  41. Thank you for all these videos and all this knowledge Doctor.
    More blood tests were done to try and find where the blood clots are coming from, with tests for Factor V Leiden, and turns out I have heterozygote in my DNA, and have been put on Xarelto for the rest of my life.

  42. My husband suddenly passed away aged 59 last month awaiting double hip replacement surgery from a PE caused by DVT. We had been in to see the surgeon 2 months prior and we asked him about the swelling in his legs and he did not warn us of anything or tell us to go to ER. Same thing with his pain dr. We were concerned and no one thought it was an issue. Tell that to our 13 year old daughter.

  43. I'm 24. Was given Birth Control to help with menstruation. I questioned it so much up until my leg started going to sleep for no reason. Went back to dr & they stated, " no issues yet". Another dr gave me a lecture on not eating correctly & prescribed pain meds. I came back 2 days later. Still in pain, I just fell down my stairs because my leg gave out. They gave me more pain meds & recommended vitamins < banana >. I woke my husband up the 7th day with my entire right side numb, trouble breathing & losing consciousness. Went to the ER, where they misdiagnosed me again. Said it was pneumonia. Gave me meds but thank God they did a CT of my lungs. Finally found the blood clot. They sent me to an actual hospital & now I'm on eliquis for a year. Awful situation & traumatic! Always question everything.

  44. My mother’s friend passed away two weeks ago from this unfortunately . I am very hurt about it. How can paramedics avoid death being final for a patient experiencing it in the moment ?

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