Massive PE Secondary to Physiotherapy....

Physiotherapy? That's not one of the makor risk factors for PE I hear you cry...

But that's how this scenario played out on a recent shift on the floor...

Scenario

30 something previously well female presents acutely to the ED via ambulance, after a syncopal episode in the street whilst walking home after an appointment with her physiotherapist. She had been receiving treatment for a "calf sprain" that she had complained of, with ongoing pain in her right calf for the preceding 2 weeks. Bystanders called for an ambulance, and on arrival to the ED, she was found to have a systolic BP of around 70mmHg, hypoxic with saturation of 80% on air, and tachycardic with a rate of 150 bpm. She denied having any chest pain. She was immediately transferred to a resuscitation bay, and rapidly assessed.

Click to read more ...

Bilateral submassive PE

A 42 year old lady self presented to ED with vague symptoms of mild shortness of breath on exertion. No chest pain. Completely asymptomatic at rest. No previous history, otherwise fit and well. Only medication - oral contraceptive pill.

On examnation she appeared well from the bedside, was afebrile, with normal O2 on pulse ox (99% on room air),  BP 135/70, but a resting tachycardia of 105 beats per minute.

Her ECG showed non specific T wave inversion in V2 and V3. 

Her bloods showed an elevated troponin i of 0.1 (normal <0.04), an elevated d-dimer at 2.4, but otherwise normal. 

Her CTPA showed bilateral large PEs, and subsequent bedside echo showed evidence of RV strain. 

So, in essence, clinically, the only clinical abnormality in this patient with bilateral submassive PE was a mild resting tachycardia, and vague dyspnoea on exertion. This is scary as hell, because one has to wonder how many of these so called "atypical" patients are sent home with a reassuring pat on the back, without a full workup.

The take home message here is that "vital" signs are called "vital" for a reason. Beware of sending home any patient with unexplained vitals, and remember that "stable vitals" require more than one measurement over time to demonstrate stability!

Click here for a comprehensive guideline on VTE by the AHA.

Update on Friday, December 2, 2011 at 9:10PM by Amit Maini

Scott Weingart from the wonderful emcrit blog  has summarised the AHA guidelines brilliantly..

Emcrit AHA PE summary

Jeff Kline lecture on thrombolysis on massive and sub-massive PE (from emcrit.org)