Armchair Air is at it again with this is the second installment of the “Breaking the Case” series where we discuss case studies related to previously covered topics. Even though some content from Episode 33 – P.E. MERGENCY is reviewed, we recommend listening to it before proceeding. It will provide the foundation needed to understand the concepts that we base our decision-making on.
With that being said, this episode discusses three patient scenarios where pulmonary embolism plays a factor in their presentations. We discuss diagnostics and treatment methods based on the severity of each case. We also highlight the challenges surrounding the P.E. patient when resources are limited.
Case #1:
72yom, retired PCP
C/o near syncopal episode after worsening dyspnea x48hrs
Hx HTN, Prostate CA
BP 110/70, HR 112, RR 22, SpO2 88% RA
2+ LLE edema and 1+ RL, 2 DP
ECG ST with non-specific ST-T wave changes, RAD, normal intervals
CXR non-contributory
Trop 1.5ng/mL
CTA is pending
Dx Enlarged RV and bilateral central segmental PE’s per CTA
Case #2:
63yof
C/o chest pain, SOB
Hx CAD, HTN (Carvedilol), HF
BP 88/47 (61), HR 75, SpO2 91% RA
Trop 0.08ng/mL, BNP 523, BUN 24, Cr 1.4, D-Dimer elevated
ECG SR with RBBB
Dx Bil PE per CTA
TPA given
NS 1L given, #2 @ 999
Case #3:
22yof 29+4 pregnant
C/o leg swelling, SOB
Hx Gestational diabetes
BP 81/42 (55), HR 122, SpO2 87% NRB
WBC 19, Glucose 280
Planning to apply BIPAP
Asking if they should do a CTA
Currigan, D. A., Hughes, R. J., Wright, C. E., Angus, J. A., & Soeding, P. F. (2014, November 01). Vasoconstrictor Responses to Vasopressor Agents in Human Pulmonary and Radial Arteries:An In Vitro Study. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1936478
Farinde, A. (2017, January 07). Vasopressors: Effects of Various Vasopressors. Retrieved from https://emedicine.medscape.com/article/2172220-overview
Farkas, J. (2017, June 04). Eight pearls for the crashing patient with massive PE. Retrieved from https://emcrit.org/pulmcrit/eight-pearls-for-the-crashing-patient-with-massive-pe/
Prats, M. (2018, June 01). Ultrasound G.E.L. – Multiorgan Ultrasound for Pulmonary Embolism. Retrieved from http://www.emdocs.net/ultrasound-g-e-l-multiorgan-ultrasound-for-pulmonary-embolism/
Price, L. C., Wort, S. J., Finney, S. J., Marino, P. S., & Brett, S. J. (2010). Pulmonary vascular and right ventricular dysfunction in adult critical care: Current and emerging options for management: A systematic literature review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219266/#__ffn_sectitle
Simcox, L. E., Ormesher, L., Tower, C., & Greer, I. A. (2015, December). Pulmonary thrombo-embolism in pregnancy: Diagnosis and management. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818214/
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Episodes 33 and 38 were fantastic. I’m a new flight clinician and the insight provided within these episodes is priceless. Thank you.
So glad to hear that!