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Case #20 Breathless

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

A 77-year-old lady has been admitted with a fractured left pubic ramus. She has had an uneventful admission and has now been in for 7 days but is finding it difficult to mobilise. You are asked to see her as she has suddenly become short of breath. She is a non-smoker. She has no chest pain. Her BP is 11/80 mmHg. The nurses tell you that her oxygen saturation is 82% and you advise them to increase her oxygen to 15 L/min (No history of Asthma/COPD) and to get an ECG and ensure she has venous access and you tell them you will be there immediately.

1. What are your suspicions as you hurry to see her. What is the differential of acute breathlessness in this setting

Pulmonary embolism
Acute pulmonary oedema due to LVF (unlikely if no cardiac hx and no chest pain)
Pneumonia
Acute asthma (unlikely if not asthmatic)
Pneumothorax
Anaphylaxis -no allergens, no wheeze or urticaria
Diabetic ketoacidosis and Kussmaul breathing - she is not diabetic

2. What are the issues to assess

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 bloods. Is a D dimer useful

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

You request an urgent CTPA and discuss it with the radiology SPR. If other diagnoses such as infection 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

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

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

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

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

Answer

10. Question

Answer

References

NICE on Pulmonary embolism

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