Questions for Discussion:

  1. What is the problem list for this patient on presentation to the emergency room? What is the differential diagnosis for each problem?
  2. Which of these diagnoses carry the greatest risk?
  3. What are the patient's risk factors for DVT/PE?

 

PHYSICAL EXAMINATION:

Blood pressure 102/80; pulse 128; respiratory rate 32; oral temperature 37.0 C.

GEN:  She appears to be in moderate respiratory distress.  She is well developed and nourished. 

HEENT:  There is no tracheal deviation. 

CV:    Examination of the heart revealed an accentuated pulmonic component of the second sound. 

PULM:    Her breathing is rapid and shallow.  There is dullness to percussion and decreased breath sounds in the left base.  There were no rhonchi or crackles or sounds of  increased voice transmission. 

ABD:  The abdomen, pelvic and rectal exams were normal. 

EXT:   The extremities showed no edema, cyanosis or clubbing.  The shoulders revealed normal range of motion; no warmth or tenderness was noted.  The other joints are normal.

  1. Which of the diagnoses is supported by the physical exam? Does the normal extremity exam rule out DVT?
  2. Interpret the findings on lung and cardiac exam.

LABORATORY TESTS:

The emergency room physician orders the following tests:

 

CBC:                \       15       /                                            140  |  105  |  10  /       

                 11.5   -------------                                  ------------------------  85

                         /      43       \                                3.8  |   24   |   0.7 \

                     

                 (83 polys, 1 band, 14 lymphs).

 

Blood Gases:

FIO2                      pH                   PCO2               PO2                  

0.21                       7.48                   30                 80        

 

EKG:      

 

 

 

 

 

 

 

  1. Interpret the arterial blood gases.
  2. Calculate the alveolar-arterial oxygen gradient.
  3. Do the EKG findings support your diagnosis?.
  4. What is your pre-test probability that she has a PE?
  5. The following are tests that can be ordered for evaluation of patients with suspected acute PE. Describe a scenario when each test would be appropriate and which test should be ordered on our patient?
    a. Chest X-ray
    b. D-dimer
    c. CT-PE protocol
    d. LE Doppler
    e. VQ scan
    f. Echocardiogram
  6. How are VQ scans reported when considering pulmonary embolism?

    CXR is done

     

  7. Interpret the CXR findings.
  8. Is there anything on the CXR to explain the left shoulder pain?
  9. Imaging is positive for left sided PE. Should she be admitted? What is her simplified PESI score?
  10. The following are optionsn for treatment of acute PE/DVT. Explain when each treatment option would be appropriate and which would you choose for our patient?

     

    a)      Unfractionated heparin infusion

    b)      Low molecular weight heparin

    c)      Warfarin (Coumadin)

    d)     Rivaroxaban (Xarelto)

    e)      Dabigatran (Pradaxa)

    f)       Aspirin

  11. How long should outpatient therapy be maintained in our patient? 

    Fill in the “recommended duration of anticoagulation” for each of the VTEs mentioned below:

     

     

    Risk of recurrence after 1 year

    Risk of recurrence after 5 years

    Recommended duration of anticoagulation

    VTE provoked by surgery:

     

     

     

     

    VTE provoked by nonsurgical reversible factor (estrogen, pregnancy, leg injury, flight >8hrs):

     

     

     

     

     

    Unprovoked VTE

     

     

     

    Provoked VTE with persistent risk factor (antiphospholipid syndrome or other inherited thrombophilias)

     

     

    VTE in setting of cancer

     

     

     

     

     

     

    Unprovoked isolated distal DVT

     

     

     

     

     

     

     

  12. What treatment would you suggest in the following scenarios?

A. Systemic Thrombolysis

B. Catheter-directed thrombolysis

C. Anticoagulation with Lovenox or DOAC (Apixiban) 

  • BP 140/85, HR 100, RR, 30, O2 sat 92% on room air, mild respiratory distress.  Saddle embolus found on CTA chest. 

C
  • BP 70/45, HR 140, RR 32, O2 sat 90% on NRB.  PE noted in subsegmental branch of pulmonary artery on right

A
  • BP 70/45, HR 140, RR 32, O2 90% on NRB.  PE noted in subsegmental branch of pulmonary artery on right.  Hx of multiple GI bleeds requiring ICU stay, most recently 2 weeks ago.

B
  • BP 120/80, HR 90, RR 25, O2 93% on RA.  Multiple PEs noted bilaterally on CT.  Troponin +, BNP elevated, right heart strain on echo. 

C
  • BP 128/70, HR 95, RR 22, O2 92% on RA on admission.  Large PE in R main pulmonary artery.  Patient started on lovenox and admitted.  On hospital day #2, patient is more hypoxic with BP now 100/70, HR 110, RR 30 and O2 sat 92% on NRB. 

A

 

 

18. What would you tell the patient to do to prevent future DVT and PE?

 The patient is discharged home on your recommended therapy. She returns to the ER 10 days later with coffee ground emesis. Her hemoglobin has dropped from 15 g/dL to 10g/dL.

19. What can you do if the patient has a major contraindication to the standard therapy for DVT/PE?  

·         Antithrombotic Therapy for VTE Disease, 10th ed: ACCP evidence-based clinical practice guidelines. CHEST 2016;149 (2) 315-352 

·         Acute Pulmonary embolism. NEJM 2010; 363:266-274. 

·         Multidetector CT for acute PE.  PIOPED II.  NEJM 2006;2317-2327. 

 

·         Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).  JAMA. 1990 May 23-30;263(20):2753-9 

·         Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism.  Blood. 2014 Mar 20;123(12):1794-801 

·         SIMPLE Case # 30.  MedU portal.

 

 

 

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