Sim Lab 4 - Pulmonary Embolism

Diagnosis/Assessment: Pulmonary Embolism


Chief Complaint: Shortness of Breath/Chest Pain


HPI/Patient Presentation:

Mr. Smith is a 66 yo male who is presenting to the ED complaining of chest pain and shortness of breath. Pt. states that the chest pain started 4 hours ago is right sided and sharp/stabbing. He rates it as an 8/10, pain does not radiate.

If asked by the team: Returned yesterday from a vacation to the Philippines. No recent surgeries, no active malignancy, no history of DVT.


PMH:

HTN - HCTZ 25mg, Lisinopril 20mg, Metoprolol 25mg

DM2 - 500mg Metformin BID

CAD - ASA 81mg

HLD - Atorvastatin


Monitor and Vital Signs:

Initial: Sinus Tachycardia

  • HR: 106
  • BP: 106/74
  • RR: 32, shallow
  • O2%: 88%
  • Temp: 99.6
  • Glucose: 380

Decompensation: NSR without a pulse (PEA)

  • HR: 67
  • BP: 18/12
  • RR: 40
  • O2%: 68%
  • Temp: 99.6
  • Glucose: 380

After 2 minutes of CPR, 1mg epi pushed, norepi and dobutamine pressor drip started, arterial line placed: Sinus Tachycardia

  • HR: 126
  • BP: 130/74
  • RR: 0
  • O2%: 66%
  • Temp: 99.6
  • Glucose: 380

cardiac ultrasound performed showing D shaped RV, pt. is in respiratory failure due to resp. muscle fatigue, can decide to intubate (discussed in take home points), BP and HR slowly decreases then bottoms out and pt. loses pulse: NSR

  • HR: 67
  • BP: 18/12
  • RR: 0 (12 if intubated)
  • O2%: 68%
  • Temp: 99.6
  • Glucose: 380

after 2 mins of CPR pulse returns: Atrial Fibrillation

  • HR: 92
  • BP: 118/92
  • RR: 0 (12 if intubated)
  • O2%: 66%
  • Temp: 99.6
  • Glucose: 380

A few seconds after tPA is administered: V. Fib

After 1st shock, 1mg epi push and 2 min of CPR: Atrial Fibrillation

  • HR: 76
  • BP: 156/94
  • RR: 0 (12 when intubated)
  • O2%: 86%
  • Temp: 99.6
  • Glucose: 380

Physical Findings:

  • General: distressed
  • CV: tachycardic, no m/r/g
  • Resp: CTA and equal b/l
  • MSK: Positive DVT tenderness in LLE

Diagnostics/Management:

Initial:

  • IV, O2, Monitor, Vitals
  • hang 1L NSS wide open
  • CXR, EKG, CBC, BMP, troponin, BNP, ABG
  • Chest CTA, can do bedside dual doppler while awaiting IV contrast to circulate
  • Administer SC LMWH 1mg/Kg q 12hrs while patient is hemodynamically stable, can add warfarin to target INR of 2.5 (range of 2-3) but this is more for chronic management and does not need to be added immediately.

Post Decompensation:

  • bedside echocardiography (shows maximally dilated RV, with minimal EF and D shaped LV, with McConnell's sign)
  • hold IVF, start norepinephrine (2-12mcg/min, max of 30mcg/min) and dobutamine (2-5 mcg/kg/min, max of 20mcg/kg/min) pressor drips
  • place arterial line
  • obtain central line if feasible or peripheral access is insufficient
  • can decide to intubate while pt. is in ROSC, is normotensive, and has complete ventilatory failure, and after the art. line and pressor drip has been started, discuss the pluses and minuses of intubating the unstable PE patient.
    • CXR to confirm ETT placement and NG or OG tube when possible
  • serial ABGs
  • thrombolysis with tPA (50mg over 2mins)

Diagnostics Results:

  • CXR unremarkable
  • CBC wnl
  • BMP wnl
  • dual LE doppler shows DVT in LLE
  • Patient codes in the CT scanner before the scan is completed, but it would have shown a massive PE.
  • EKG shows sinus tachycardia and inverted T waves in leads II and III.

Take-Home Points:

  • Clinical Application of Wells Score, PERC Rule
  • Most common vein for a DVT:
  • ABG findings in PE: respiratory alkalosis
  • Cardiac US in PE: D shaped LV, Very Dilated RV, McConnell's Sign: akinesis of RV mid free wall w/ normal motion at the apex (77% sensitivity, 94% specificity),
  • IVC U/S will show minimal collapse with inspiration due to increased RA and RV pressures
  • Continue chest compressions after giving tPA if the echo shows akinetic RV, even if the patient has a pulse
  • SC LMWH is preferred over UFH for initial anticoagulation for high suspicion of acute PE WITHOUT SHOCK or HYPOTENSION,  (unless the patient is morbidly obese [due to the effect of increased adipose increasing the half life of SC LMWH] or has decreased renal function [due to the fact that LMWH is renally cleared], in both of those cases IV UFH is preferred)
  • IF Pt. is presenting with Acute PE and IS IN SHOCK, initial anticoagulation with UFH IS PREFERRED
  • for boards: ABG results in acute pulmonary embolism will show respiratory ALKALOSIS due to V/Q mismatch
  • Pressors of choice in acute PE: norepinephrine and dobutamine
  • Intubation in hemodynamically unstable PE is extremely risky, don't do it unless they have a good pressure and you already have them on pressors and the patient absolutely requires intubation due to complete respiratory failure in the presence of a perfusing rhythm: place arterial line prior to intubation, make sure if you have to induce you choose cardiostable induction meds (e.g. ketamine) and maintain low TV, normoxia, normocapnea and limit the PEEP as necessary
  • giving IVF is of little benefit if the RV is already dilated, the pt. is in shock, and is requiring vasopressors, however, can be of benefit in the earlier stages of an acute PE

References: