PE

Question 1

A 32 year old woman is receiving chemotherapy for breast cancer. On the fourth day of her hospitalisation she becomes acutely short of breath. Her T is 37.4, PR is 120, BP100/85, RR 32, sats 88%. How would you assess and manage her.

Answer 1

Impression
Given sudden onset respiratory compromise in setting of cancer and chemotherapy, I am most concerned about PE, this being a medical emergency warranting immediate assessment and management.

The patient has several risk factors for VTE and PE according to Virchow’s triad including; cancer, immobility, chemotherapy.

DDx to consider:

• Cardiac: ACS, dissection, etc (unlikely in absence of chest pain)
• Respiratory: infective (neutropenic sepsis, pneumonia), pneumothorax, atelectasis, COPD, asthma, anaphylaxis, foreign body inhalation
• Anxiety/panic attach

Goals

• MERT call, assemble team for A to E assessment and emergent management
• Utilise Wells criteria and diagnose with CT-PA or arterial chest if uncertain
• Emergent management with anticoagulation (heparin infusion), consider clot retrieval/thrombolysis if unstable.

Question 2

PE - Assessment

Answer 2

Assessment

• MERT
• assemble team

A - patent, maintaining, likely no abnormality
B - RR, SP02 monitoring. Resp exam for area of reduced air entry, WOB assessment. administer supplemental 02 starting with Hudson mask and can escalate to bag + valve, consider intubation (pending GCS and response)
C - 2xIVC (for bloods and infusions), monitoring, initial bloods (VBG, FBC, coags, LFT), ABG for hypoxia - need CTPA/VQ for definitive diagnosis, CXR at bedside if not
D - GCS

Management stratified by type of PE;
massive: hypotenison and R heart strain
sub-massive, normotensive, R heart strain
other: normotensive, no R heart strain
Therefore, conduct clinical assessment to determine which of these is implicated.

Signs of right heart strain:

• clinical: Raised JVP, parasternal heaves, loud P2
• ecg: RBBB, sinus tachy, S1Q3T3
• Echo:
• biomarkers: elevated BNP and Trops

Question 3

PE - History

Answer 3

History

• take concurrently with patient as available
• review notes; checking current management plan, any VTE prophylaxis that has been administered,
• Sx: chest pain, pleuritic, haemoptysis, calf tenderness/swelling, SOB, diaphoresis, etc
• RISKS: Virchow’s triad (stasis, endothelial injury, pro-thrombotic state)
• PMHx:
• Meds: COCP

Question 4

PE - Examination

Answer 4

Examination

• General appearance + vitals (re-check, continuous monitoring)
• Resp exam: air entry, WOB (Accessory muscles),
• Cardiac exam: tachycardia, elevated JVP
• Calf exam: swelling, tenderness, erythema

Question 5

PE - Investigations

Answer 5

Investigations
- apply Wells Criteria for Pre-test probability of PE, investigate accordingly.

Key

• CTPA as per Wells
• D-Dimer as per Wells
• Bedside: ECG for s1Q3T3 or sinus tachy, other non-specific qrs/ST segment changes
• Bloods: FBC, CRP/ESR, trops, coags, UEC,
• Imaging: CXR for other respiratory pathology

Question 6

PE - Management

Answer 6

Management
Definitive
Stratified based on whether stable or unstable, and massive vs sub-massive vs other.
- use enoxaparin in cancer patients as not enough evidence for warfarin or NOACS.

Stable
- Anticoagulation with SC enoxaparin/clexane/LMWH if really impaired (LMWH better in malignancy)

Unstable

• Anticoagulation +/- thrombolysis +/- embolectomy and anticoagulation (SC enoxaparin [clexane]).
• thrombolysis: streptokinase bolus + infusion, completed in conjunction with senior colleagues.
• check antiXa at 4 hours if LMWH, regular aPTT monitoring for UFH and follow local guidelines for therapeutic range.

Long-term

• if recurrent or ongoing elevated risk, then IVC filter.
• consider thrombophilia screen if suspicious
• ongoing anticoagulation and repeat imaging/investigations @3-6mnths to guide length of anticoagulation therapy.