Makindo Medical Notes

• Has she been on VTE prophylaxis - you find out that she has not had an assessment. TED stockings were prescribed but she could not wear them
• Has she a history of VTE - no
• Her BP is 110/80 and pulse is 11/min
• Her JVP is elevated.
• Her chest is clear - no crackles of oedema
• Her left leg appears swollen?? DVT
• Her ECG shows sinus tachycardia and is otherwise normal
• She has a cannula in place.
• Her saturations are 96% on 5 L/min of oxygen
• Respiratory rate is 25/min
  

  3. You send some blood. Is a D dimer useful

  See Answer
  It is reasonable to do and many will also send a troponin but this is highly likely to be a PE and needs a CTPA. A CXR is unlikely to be helpful as the diagnosis is quite certain. The CT will look at lung parenchyma.

  4. What will you do now

  See Answer

  • You request an urgent CTPA and discuss it with the radiology SPR. If other diagnoses such as infection are equally likely (fever, cough, raised WCC, signs of consolidation) they may suggest a CXR first. This, however, seems clear cut.
  • You start IV fluids 0.9% saline over 4 hours to ensure right-sided filling pressures which will help the BP
  • There will be a wait of 2 hours for the scan as there is a multiple trauma in ED
  • Therefore prescribe a stat dose of Enoxaparin 1.5 mg/kg or equivalent if no contraindications such as a high risk of bleeding

  5. The tests is positive - what is next

  See Answer

  The CTPA shows bilateral segmental PE

  • Therefore prescribe Enoxaparin 1.5 mg/kg once a day or consider a DOAC
  • Assess bleeding risks. Discuss risks and benefits of anticoagulation
  • Explain to the patient as this is first provoked PE need treatment for at least 3 months

  6. If the patient had had a recent subdural haemorrhage what alternative to anticoagulation might you consider

  See Answer

  An IVC filter is inserted for several weeks until bleeding risk falls and anticoagulation can be restarted. They are then removed. They will not help this PE but will help to prevent further.

  7. If the patient had been shocked with low BP what might you have done differently

  See Answer

  One would have wished for supporting evidence for the diagnosis either with an echocardiogram or the CTPA and if confirmed then Thrombolysis would be considered depending on bleeding risk.

  8. If the patient had been 32 years old and pregnant with a fracture what would you have done differently

  See Answer

  The diagnostic test would have been a USS of the left leg and if a clot was seen then anticoagulation started on that basis. A CXR (fetal shielding) would be done to exclude other diagnoses. And if still unclear then a CTPA with shielding of the fetus might be considered. The fetus is not the concerned with radiation as can be shielded. It is radiation to the female pregnant breast with concerns of breast cancer later in life.

  9. Question

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  Answer

  10. Question

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  Answer

References

• NICE on Pulmonary embolism