PR 128/min, BP 110/70, RR 28/min, SPO2 99% on Room Air
ECG - Sinus Tachy
PaO2 - 14kP (105mmHg)
I booked her for a CTPA on arrival since she was high-risk so d-dimer was not needed. Over the next hour, with some IV Fluids, her vitals settled down and looked a bit better.
PR 110/min BP 120/68 RR 24/min SPO2 99% Room Air
This made me wonder if a scan was really needed for her? Anyways, she was already on oral anticoagulation. Would I be able to justify myself for not doing a CTPA with textbook presentation of PE?
I ended up scanning her and she was found to have sub-segmental PEs. You might argue against a CTPA for this patient but her presentation and initial vitals kept me on my toes.
My learning points from this case:
- Normalization of initially abnormal vital signs should not be relied upon to r/o PE
- ABG and pulse oximetry do not reliably predict the presence or absence of PE
- Massive PE is defined as acute PE with obstructive shock or SBP <90 mmHg
- Submassive PE is acute PE without systemic hypotension (SBP ≥90 mm Hg) but with either RV dysfunction or myocardial necrosis (positive troponin or ECHO evidence of RV dysfunction)
- Low risk PEs
(1) Patients with contraindications to anticoagulation
(2) Those who have complications from the use of anti-coagulation
(3) Those who fail to attain adequate anticoagulation while undergoing treatment.
Cather directed lysis should be first line if available for massive PE.
- Treat with Heparin Doppler if positive for DVT
- ECHO/Troponin to further risk stratify
- CTPA (Radiation is 4 times more than that of a V/Q scan)
- VQ Scan (done only if CXR is normal, if CXR abnormal then go for CTPA)
Consider targeting higher INR as they are throwing clots even on oral anti-coagulants.
- Age-Adjusted d-dimer
- Tichauer M. The Emergency Medicine Approach To The Evaluation And Treatment Of Pulmonary Embolism. Emergency Medicine Practice. 2012:2.
- Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, Part 2: diagnostic approach. The Journal of emergency medicine. 2015 Jul 31;49(1):104-17.