Trauma and Critical Care—Pulmonary Embolism
Concept
Life-threatening postoperative complication. Will likely be from femoral or iliac DVT. Usually associated with trauma, stasis, and hypercoagulability (Virchow’s triad).
Don’t spend time here worrying about inherited defects like FV Leiden or Protein C/S deficiencies—question is regarding resuscitation, diagnosis, and definitive treat- ment.
Way Question May be Asked?
“Called by nurse to evaluate a 45 y/o male POD#5 sig- moid colectomy now anxious, with HR 110s and pulse ox 85% on supplemental O2. What do you do?” Question may be asked several different ways with unexplained anxiety, change in mental status, new hypotension in ICU patient, or sudden onset, pleuritic chest pain. Need to be method- ical, but expeditious, or your patient will die and you’ll be back to take the exam next year.
How to Answer?
Think of history and physical exam while resuscitating pt:
Supplemental O2, IVF, EKG, CXR, ABG, transfer to ICU
History
Risk factors:
Prior DVT Malignancy Pregnancy Obesity
Prolonged immobility/Length of sugery Recent trauma
Recent surgery (especially lower extremity fractures)
Symptoms:
Chest pain Dyspnea Hemoptysis Anxiety
Physical Exam
Check vital signs, pulse ox (tachycardia, tachypnea) Lung sounds
Neck veins
Diagnostic Tests
CXR (usually normal but may show decreased pulmonary vascularity, will r/o CHF or pneumothorax)
EKG (may show signs of right heart strain with T wave and ST segment changes, need to r/o MI)
Blood gases (hypoxia and hypocarbia, very unlikely to be PE if PO2 > 90)
+/− CVP (will be elevated) V/Q scan
Spiral CT scan (good for large PE’s) Pulmonary Angiogram (gold standard)
Surgical Treatment
(1) Resuscitate the pt O2, fluids, transfer to unit (2) Anticoagulation
heparin bolus to keep PTT 2–3 times normal value 80U/kg bolus followed by 18U/kg continuous infu-
sion
(Can use LMWH-lovenox at dose of 1mg/kg Q12) (3) Thrombolytics
for pt with ongoing shock despite maximal support- ive care (pressors, fluids, intubation, Swan-ganz catheter)
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can’t use in pt with recent hemorrhagic stroke, intracranial neoplasm or recent trauma, recent intracranial procedure, active/recent internal bleeding
(4) Surgical embolectomy
for pt with contraindication to thrombolytics or failure of thrombolytics with impending cardio- vascular collapse
can support pt with femofemoral AV partial bypass until operation
(5) IVC filter
for pt with recurrent PE despite therapeutic antico- agulation
for prophylaxis in pt with DVT and contraindica- tion to anticoagulation
for pt s/p pulmonary artery embolectomy
Common Curveballs
Fresh post-op pt (colectomy, AAA repair)
Pt will have recent bleeding duodenal ulcer or divertic- ular bleed
HIT after administering heparin Recurrent PEs on therapeutic heparin Being asked how to dose heparin/coumadin
Forcing you to do surgical embolectomy or use throm- bolytics
Pt will be pregnant (can’t use coumadin in first trimester of pregnancy)
Strikeouts
Giving thrombolytics to fresh post-op pt, or pt with recent intracranial bleed/trauma/procedure
Not knowing indications for IVC filter
Sending pt for V/Q scan/Spiral CT scan/angiogram before starting Heparin
Missing diagnosis (treating as MI or sepsis) Discussing suction catheter embolectomies
Spending too much time on hypercoagulable work-up or on H+P in unstable pt.
Not putting patients in ICU
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