Pulmonary Embolism

Question 1

A 36 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°C, PR is 120/min, BP 100/85mmHg, RR 32/min and O2 saturation 88%. How would you assess and manage her?

Imp/DDx/Goals

Answer 1

Impression
Acute onset of respiratory illness in setting of hospitalisation and likely immobilisation, concerned about a pulmonary embolus. Other red flag diagnoses to rule out include ACS, Pneumothorax, or acute bleeding. Would consider other respiratory causes including infection (pneumonia), atelectasis.

Goals

• identify aetiology of acute respiratory illness
• initiate appropriate emergent and ongoing treatment/management

Question 2

PE - Assessment

Answer 2

Assessment
Would take an A-E approach given severity and acuteness of onset. concerned about haemodynamic instability.
A - patent, maintaining. Adjuncts as required
B - RR, sats, continuous monitoring. Initiate supplemental and escalate according to response to sats
C - IV access, BP monitoring. consider art line insertion. Take initial bloods and administer fluid bolus
D - GCS
E - secondary survey

If high clinical suspicion of DVT, begin anticoagulation therapy with apixaban with consult from senior colleague, involve ICU/ escalate care.

Question 3

PE - History

Answer 3

History

• sx/RFs: haemoptysis, pleuritic chest pain, SOB, dyspnoea, instability. time-course of onset, calf pain
• HxPC: happened before
• risk factors: (Virchow triad) immobile, no DVT prophylaxis, clotting disorder, on OCP
• Wells criterai +/- PERC rule
• PMHx, recent surgical
• Medications: OCP, anticoagulants
• SNAP (cardiovascular disease risk)

Question 4

PE - Examination

Answer 4

Exam

• General obs + vitals
• Cardiorespiratory examination: unequal air entry,

Question 5

PE - Investigations

Answer 5

Investigations
Utilise Wells Criteria to calcualte pre-test probability and inform test of choice
- Bedside: vitals, VBG, ECG, CXR (low sensitivity)
- Bloods: FBC, UEC, trops, pre-surg (gropu + hold, coags), D-Dimer
- Imaging: CXR, CT-PA, VQ scan, doppler ultrasound (DVT)

Question 6

PE - Management

Answer 6

Management
Initial/Supportive:
- supplemental O2
- fluids +/- BP support (pressors)
- analgesia

Stable:
- empirical anticoagulation

Unstable:

• fibrinolysis + parenteral anticoagulation
• surgical thrombectomy if available and not contraindicated

Ongoing:

• DVT prophylaxis
• regular obs
• long-term anticoagulation
• respiratory physician follow-up
• consider role for IVC filter if at increased risk for subsequent PE