Emergency Medicine Pulmonary Embolism Case File

https://medical-phd.blogspot.com/2021/05/emergency-medicine-pulmonary-embolism.html

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 16
A 34-year-old man presents to the emergency department (ED) complaining of shortness of breath
and chest pain that he describes as right sided and increased with deep breathing. He states it started
suddenly when he woke up and was worse with activity. He denies fever, chills, nausea, vomiting,
or cough. He has a recent history of multiple gunshot wounds resulting in ongoing pain in his upper
back and T-10 paraplegia. One week ago, he was discharged from the hospital to a rehabilitation
facility. He is currently taking acetaminophen/hydrocodone and ibuprofen for his pain, which has
increased with his physical therapy and occupational therapy. He is also taking hydrochlorothiazide
and lisinopril for hypertension and fluoxetine for depression. He recently quit smoking tobacco
since he was hospitalized and denies any alcohol or illicit drug use. On physical examination, he is
an otherwise fit young man who appears slightly short of breath and uncomfortable. His heart rate
is 101 beats per minute, his blood pressure is 110/78 mm Hg, and his respiratory rate is 26 breaths
per minute. His pulse oximetry is 96% on 2 L of O 2 by nasal canula. His lungs are clear to
auscultation. There is mild swelling of his left calf. He has no sensation in his lower extremities.
Laboratory studies reveal a white blood cell count (WBC) of 10,000/mm . Hemoglobin, hematocrit,
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electrolytes, and renal function are all within normal limits. A 12-lead electrocardiogram (ECG)
reveals a sinus rhythm at a rate of 103 beats per minute. His chest radiograph reveals minimal
bibasilar atelectasis but no evidence of infiltrates or effusions.

⯈ What is the most likely diagnosis?

⯈ What is your next diagnostic step?

ANSWER TO CASE 16:

Pulmonary Embolism

Summary: A 34-year-old man with hypertension, depression, and recent gunshot wounds resulting
in T-10 paraplegia presents with dyspnea, pleuritic and right-sided chest pain, tachypnea,
tachycardia, left calf swelling, and bibasilar atelectasis on chest radiography.

 Most likely diagnosis: Pulmonary embolism (PE) secondary to deep venous thrombosis

(DVT) in the left lower extremity.
 Screening and confirmatory studies: For evaluation of PE, D-dimer level, venous duplex
ultrasonography, ventilation-perfusion scan (V/Q scan), pulmonary CT angiography, and
catheter pulmonary angiography are available and may be applied on a selective basis.

ANALYSIS
Objectives
 1. Learn the clinical presentations of PE.
2. Learn to formulate reasonable diagnostic strategy for the diagnosis of pulmonary embolism
in the emergency department setting.
3. Learn the sensitivity, specificity, and limitations of the D-dimer test and the contrast-
enhanced helical computed tomography angiogram for the diagnosis of DVT and PE.

Considerations
This 34-year-old patient who has been immobilized has a primary risk factor for venous
thromboembolism. The presentation of acute dyspnea, chest pain, borderline tachycardia, and
unilateral lower extremity swelling in the absence of identifiable alternative cardiopulmonary
disease place him in the high-risk category for a pulmonary embolism. An ECG in patients with
suspected PE is generally helpful for identifying other etiologies of his symptoms such as ischemic
heart disease, pericarditis, and dysrhythmias. In some instances, the ECG may reveal right-heart
strain patterns that are more specific for the diagnosis of PE. Although nonspecific, sinus
tachycardia is still the most frequent presenting ECG finding among patients with PE. Even 25% of
patients with identified PE may have a normal ECG. The relatively normal chest radiograph is
valuable in eliminating alternative diagnoses, such as pneumonia, pneumothorax, and congestive
heart failure. An arterial blood gas can be used to assess patients with shortness of breath, but it is
non-specific in the diagnosis of PE. Taking into consideration the clinical, radiographic, and ECG
data, a presumptive diagnosis of PE can be made. The next steps in management include
maintenance of cardiopulmonary stability, consideration of empiric anticoagulation therapy, and
confirmation of the diagnosis.

Approach To:
DVT and PE

DEFINITIONS
DEEP VENOUS THROMBOSIS: Formation of clot (thrombus) in a deep vein (a vein that
accompanies an artery). Eighty to ninety percent of diagnosed PEs arise from a DVT of the lower
extremity. However, thrombi of deep veins in the calf (tibial veins) are difficult to detect, but also
much less likely to embolize than more proximal thrombi.

PULMONARY EMBOLISM: Blockages of the pulmonary arteries, most often caused by blood

clots originating from deep veins in the legs or pelvis. In rare circumstances, air bubbles, fat
droplets, amniotic fluid, clumps of parasites, or tumor cells may also cause a PE. Risk factors for
thrombosis are related to Virchow triad of hypercoagulability, venous stasis, and venous injury.

D-DIMER ASSAY: Fibrin D-dimer is released into the circulation following degradation of cross

linked fibrin by plasmin. Multiple commercial assays are available that use a monoclonal antibody
to detect the D-dimer fragment. The two most commonly used assays are the whole blood
immunoagglutination test (less accurate) and the quantitative plasma ELISA assay (more accurate).
Elevated levels may indicate the presence of concurrent thrombus formation and degradation. Other
conditions in which D-dimer elevation occurs include sepsis, recent myocardial infarction or stroke
(<10 days), recent surgery or trauma, disseminated intravascular coagulation, collagen vascular
disease, metastatic cancer, pregnancy, hospitalized patients and liver disease. The D-dimer may be
falsely negative if clot formation is greater than 72 hours before the blood is assayed. Conversely, it
may be falsely positive since levels may remain elevated for as long as 2 years. In pregnancy, the
upper limits of normal are increased with each trimester, but a true normal D-dimer should never be
greater than 1000 μg/L.

VENOUS DUPLEX ULTRASONOGRAPHY: Ultrasound imaging modality combining direct

visualization of veins with Doppler flow signal to assess luminal patency and compressibility of the
deep venous system in the extremities and the presence of thrombosis. This imaging modality is
most accurate for assessment of the iliac, femoral, and popliteal veins.

PERFUSION AND VENTILATION (V/Q) SCAN: Radioisotope used to identify ventilation

perfusion mismatches. Results are categorized into probabilityranked groups after taking into
account of coexisting pulmonary pathology and the patient’s overall clinical picture. Radiologists
interpret V/Q scans as normal, low, intermediate or high probability for V/Q mismatch or PE in the
right clinical setting. Unfortunately, many patients with known PE have nondiagnostic V/Q scans,
and these low to intermediate probability scans have significant disagreement among interpreters.
Current literature indicates its benefits primarily in renal failure when contrast may precipitate renal
failure. V/Q scans may also be the test of choice for pregnant patients. It is reported that
multidetector CT (MDCT) scanning has higher radiation exposure for the mother but lower fetal
radiation exposure, whereas V/Q scan has lower maternal and higher fetal radiation exposure.
Remy-Jardin recommends perfusion scintigraphy (Q) without ventilations scintigraphy (V), which
significantly decreases fetal radiation exposure.

COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY (CTPA): Magnified CT

imaging of the pulmonary vasculature obtained during the arterial phases of venous contrast
injection. While highly specific for PE, the reported sensitivity is variable and ranges from 50% to
90%. The diagnostic sensitivity is higher for centrally located PE but reduced for subsegmental
clots. The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) study
suggests that CTPA identifies more PE than V/Q scanning, but these may be false-positives or clots
that do not require anticoagulation. The diagnostic accuracy is also related to observer expertise.
The initiation of multidetector CT scanning has greatly improved imaging of central, segmental,
and subsegmental arteries. An advantage of this modality is its ability to detect alternative
diagnoses. Pulmonary MDCT angiography has a reported sensitivity of 83% and a specificity of
96% in PIOPED II.

PULMONARY ANGIOGRAPHY: Imaging involving intravascular contrast injection and

fluoroscopy to determine patency of the pulmonary arterial vasculature. Although once considered
the gold standard for diagnosing PE, this test has largely been replaced by pulmonary CT
angiography (CTA). Baile et al showed that these two tests had no difference in the detection of
subsegmental sized PE. They concluded that pulmonary CTA and pulmonary angiography are
comparable for detecting PE. Pulmonary angiography is invasive and is associated with increased
morbidity and mortality when compared to CTA.