Session 3
Circulatory course
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ARTERIAL THROMBOSIS
• Acute vascular occlusion may be caused by an embolus or acute
• Thrombosis.
• Acute arterial occlusions may result from iatrogenic injury, which can occur during insertion of invasive
catheters such as those used for
1. arteriography, PTA or stent placement,
2. an intra-aortic balloon pump.
3. Other causes include trauma from a fracture, crush injury, and penetrating wounds that disrupt the arterial
intima.
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Pathophysiology
Arterial emboli arise most These thrombi become Emboli may also
commonly from thrombi detached and are carried develop in advanced
that develop in the from the left side of the aortic atherosclerosis
chambers of the heart as a heart into the arterial
result of atrial fibrillation, system, where they lodge because the
myocardial infarction, in and obstruct an artery atheromatous plaques
infective endocarditis, or that is smaller than the ulcerate or become
chronic heart failure. embolus. rough.
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Clinical Manifestations
• The symptoms of arterial emboli depend primarily on the size of the embolus, the organ involved, and
the state of the collateral vessels.
The immediate effect is
cessation of distal blood flow.
• The blockage can progress above and below the obstruction.
• Secondary vasospasm can contribute to the ischemia.
• The embolus can fragment or break apart, resulting in occlusion of distal vessels.
• Emboli tend to lodge at arterial bifurcations and areas narrowed by atherosclerosis.
• Cerebral, mesenteric, renal, and coronary arteries are often involved in addition to the large arteries
of the extremities.
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The six Ps associated with acute arterial embolism are
1. pain
2. pallor
3. pulselessness
4. paresthesia
[Link] (coldness),
6. paralysis.
Eventually, superficial veins may collapse because of decreased blood flow to the extremity. The part of the extremity
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below the occlusion is markedly colder and paler than the part above the occlusion because of ischemia.
Assessment and Diagnostic Findings
• An arterial embolus is usually diagnosed on the basis of the sudden nature of the onset of
symptoms and an apparent source for the embolus.
• Two-dimensional echocardiography or transesophageal echocardiography, chest x-ray, and
electrocardiography may reveal underlying cardiac disease.
• Noninvasive duplex and Doppler ultrasonography can determine the presence and extent of
underlying atherosclerosis, and arteriography may be performed.
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Medical Management
Management of arterial thrombosis depends on its cause.
Management of acute embolic occlusion usually requires surgery because time is of the essence.
.Heparin therapy is initiated immediately to prevent further development of emboli and to hamper
the extension of existing thrombi.
Typically, an initial bolus of 5,000 to 10,000 units is administered intravenously, followed by a
continuous infusion of 1,000 units per hour until the patient is able to undergo surgery.
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SURGICAL MANAGEMENT
Emergency embolectomy is the procedure of choice only if the
involved extremity is viable . Arterial emboli are usually
treated by insertion of an embolectomy catheter.
The catheter is passed through a groin incision into the affected
artery and advanced past the occlusion.
The balloon is inflated with sterile saline solution, and the
thrombus is extracted as the catheter is withdrawn.
This procedure involves incising the vessel and removing the
clot.
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PHARMACOLOGIC THERAPY
When the patient has collateral circulation, treatment may include intravenous anticoagulation with
heparin, which can prevent the thrombus from spreading and reduce muscle necrosis.
The use of intra-arterial thrombolytic medications helps to dissolve the embolus. Fibrin-specific
thrombolytic medications and single-chain urokinase-type plasminogen activator ……
A catheter is advanced under x-ray visualization to the clot, and the thrombolytic agent is infused.
Contraindications to thrombolytic therapy include active internal bleeding, CVA (brain attack,
stroke), recent major surgery, uncontrolled hypertension, and pregnancy.
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Nursing Management
1. Before surgery, the patient remains on bed rest with the extremity level or slightly
dependent (15 degrees).
2. The affected part is kept at room temperature and protected from trauma.
3. Heating and cooling pads are contraindicated because ischemic extremities are easily
traumatized by alterations in temperature.
4. If possible, tape and electrocardiogram electrodes should not be used on the extremity;
sheepskin and foot cradles are used to protect the leg from mechanical trauma.
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Cont`
1. If the patient is treated with thrombolytic therapy, she or he s accurately weighed in
kilograms, and the dose of thrombolytic therapy is determined based on the
patient’s weight.
2. The patient is admitted to a critical care unit for continuous monitoring.
3. Vital signs are taken every 15 minutes for 2 hours, then every 30 minutes for the
next 6 hours, and then every hour for 16 hours.
4. Bleeding is the most common side effect of thrombolytic therapy, and the patient is
closely monitored for any signs of bleeding.
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During the postoperative period,
1. the nurse collaborates with the surgeon about the patient’s appropriate activity level
based on the patient’s condition.
2. Anticoagulant therapy may be continued after surgery to prevent thrombosis of the
affected artery and to diminish the development of subsequent thrombi at the initiating
site.
3. The nurse assesses for evidence of local and systemic hemorrhage, including mental
status changes, which can occur when anticoagulants are administered.
4. Pulses, Doppler signals, ABI, and motor and sensory function are assessed every hour
for the first 24 hours, because significant changes may indicate reocclusion.
5. Metabolic abnormalities, renal failure, and compartment syndrome may be
complications after an acute arterial occlusion
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