Author: Vincent Li M.D.
HPI
- 68 year old female with PMHx HTN, HLD, breast cancer in remission who presents after near syncopal event
- Similar episodes this week that occurred with rising from seated position
- No chest pain, SOB, palpitations, numbness, weakness, vision or gait changes, tongue biting, urinary incontinence
- Denied unilateral leg pain or swelling, prolonged immobilization, active cancer, prior VTE
- Pulse ox noted at 92% on RA in ED, requiring 2L to maintain O2 sat > 96%
- Physical exam is unremarkable, lungs clear
Vitals
T 98.4F, HR 99, BP 112/55, RR 18, O2 97% on 2L NC
Clinical Course
- ECG showed NSR @ 98 BPM, no ischemic ST or T changes
- Labs unremarkable except for D-dimer, which was elevated at 5.4.
- CXR showed non-specific RLL opacity
- Bedside cardiac ultrasound showed increased RV:LV > 1
- CTA chest showed right pulmonary artery embolism extending into lobar and segmental branches, minimal RV dilatation, patchy R lung consolidation suggestive of infarcts vs pneumonia, moderate R pleural effusion, and diffuse osseous metastases
- Heparin gtt started and critical care was consulted; patient ultimately admitted to the INCU for submassive PE
- Ultimately transitioned to Eliquis and discharged on HD5 with outpatient heme/onc followup for new metastatic breast cancer
Pulmonary embolism pearls
- PE categorized as massive, submassive, and low-risk
- Massive PE: hemodynamic instability (systolic BP < 90 mmHg for > 15 minutes or SBP > 40 mmHg from baseline, or clear evidence of shock / vasopressor requirement – treatment is intravenous thrombolytics
- Submassive PE: evidence of R heart strain (by imaging or biomarkers such as troponin, pro-bnp) without hemodynamic instability – treatment is systemic anticoagulation with heparin or low molecular weight heparin, consider catheter based thrombolysis or clot extraction (no mortality benefit)
- Non-massive or submassive PE – oral anticoagulant, consider discharge if low risk by evidence based scoring system (such as sPESI)
References
1. Garrett, John S., and Anant Patel. “Pulmonary Embolism.” Edited by Jeremy Berberian. Corependium, 2023, Accessed 26 Dec. 2023.
2. Tintinalli, Judith E., et al. “Venous Thromboembolism Including Pulmonary Embolism.” Tintinalli’s Emergency Medicine, Ninth ed., McGraw Hill, New York, 2020, pp. 389–399.
