A 63-year-old hospitalized woman develops severe shortness of breath that awakens her from sleep. She underwent elective right hip replacement for severe osteoarthritis 5 days ago. She has no history of coronary artery disease. She has received enoxaparin subcutaneously for deep vein thrombosis prophylaxis.
Her blood pressure is 78/50 mm Hg, pulse is 130/min, respirations are 34/min, and oxygen saturation is 70% on room air. Jugular venous distension is present. Her lungs are clear to auscultation. There are no murmurs. Her extremities are cold and clammy.
A 12-lead ECG shows sinus tachycardia. Portable chest x-ray is ordered and preparations are made for endotracheal intubation.
Which of the following is the most appropriate next step in management?

Question

A 63-year-old hospitalized woman develops severe shortness of breath that awakens her from sleep.  She underwent elective right hip replacement for severe osteoarthritis 5 days ago.  She has no history of coronary artery disease.  She has received enoxaparin subcutaneously for deep vein thrombosis prophylaxis.
Her blood pressure is 78/50 mm Hg, pulse is 130/min, respirations are 34/min, and oxygen saturation is 70% on room air.  Jugular venous distension is present.  Her lungs are clear to auscultation.  There are no murmurs.  Her extremities are cold and clammy.
A 12-lead ECG shows sinus tachycardia.  Portable chest x-ray is ordered and preparations are made for endotracheal intubation.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9713_8887_853d_5bad86f37642_MD0002_00 Acute pulmonary embolism (PE) is further classified as submassive or massive. Massive PE is defined as causing hypotension with systolic blood pressure < 90 mm Hg or a drop in systolic blood pressure of > 40 mm Hg from baseline for > 15 minutes. Hemodynamically unstable patients (e.g., hypotension) who are not critically ill may first have a CT angiogram (CTA) or V/Q scan. If CTA or V/Q scan is unavailable and/or the patient is critically ill, a bedside transthoracic echocardiogram (TTE) is preferred to confirm the presence of right ventricular (RV) overload. Immediate thrombolytic agents are recommended in patients with RV dysfunction. This patient's presentation (e.g., new onset dyspnea, hypotension, hypoxia, jugular venous distention, and recent hip surgery) is consistent with a high probability of massive PE, and she is hemodynamically unstable and critically ill (e.g., requiring intubation). She should first undergo bedside TTE to confirm RV dysfunction, and should receive thrombolytics if positive. Recent surgery (other than intracranial or spinal) within the previous 10 days is only a relative (not absolute) contraindication to the thrombolytic therapy. (Choice A) D-dimer testing is recommended in hemodynamically stable patients with a low clinical PE probability, but this patient has a high PE probability with hemodynamic instability and would benefit more from TTE. Troponins are elevated in 30-50% of PE due to right ventricular overload and are more indicative of adverse outcomes (prognosis) rather than diagnosis. (Choice D) Right heart catheterization may show elevated right-sided pressures in the setting of massive PE, but is significantly more invasive compared to bedside TTE. Furthermore, transport may be unsafe or unfeasible in this critically ill patient. Educational objective: A massive pulmonary embolism (PE) usually presents with acute dyspnea and hypotension, with systolic blood pressure < 90 mm Hg or a drop in systolic blood pressure of > 40 mm Hg from baseline for > 15 minutes. Critically ill and hemodynamically unstable patients should first have a bedside TTE to look for RV dysfunction, with immediate thrombolytics given for positive results. __________ References: Emergency department focused bedside echocardiography in massive pulmonary embolism. (http://www.ncbi.nlm.nih.gov/pubmed/21820258)

A 63-Year-Old Hospitalized Woman Develops Severe Shortness of Breath That