Episode 38 – Breaking the Case: P.E. MERGENCY

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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