Post Operative Pulmonary Embolism

Patient Presentation:
A 22-year-old female, K.S. presented to the ED 7 days status post T4 to L1 posterior spinal fusion due to progressive idiopathic scoliosis. She had been discharged home 2 days prior and had been doing well until yesterday evening where she developed acute onset of right-sided chest pain that worsened overnight to a sharp right sided pleuritic chest pain accompanied with severe shortness of breath. Along with Percocet® PRN for post operative pain management, pt K.S. takes oral contraceptives daily which she has taken for the past two years. Pt denies cough, fever, or sputum production. K.S.’s posterior spinal incision is intact with no evidence of drainage or redness. Pertinent findings include respiratory rate of 30, shallow breathing, anxiety, and lung sounds revealing mild decreased breath sounds on the right side with no wheezing, rales or rubs noted. VS include T-37.0, P-121, BP-114/72, SaO2 90% on room air.

Diagnosis:
EKG: reveals sinus tachycardia and non-specific S-T wave changes
Labs: CBC: Hgb-9, Hct-30, WBC-11,500
D-dimer: 0.60 µg/L, positive/elevated
ABG: pH 7.47, PaCO2 31, HCO3 20, PaO2 80, SaO2 90%
Chest X-Ray: reveals small pleural effusion in the right base, right diaphragm is elevated.
Spiral Lung CT scan with IV contrast: Multiple bilateral pulmonary emboli, patchy opacities within the right lower lobe, small right pleural effusions.

Physical exam, x-rays, and CT scan of the chest revealed a diagnosis of Acute Right Lower Lobe Pulmonary Embolism.

Treatment:
K.S. was then admitted to the ICU where anticoagulation therapy was initiated via high dose heparin drip with the goal PTT of 60-85 seconds. She was placed on supplemental O2 to maintain O2 sat >96%. She was also given oral Coumadin®, which will be given for a duration of 3 months with a goal INR of 2-3.

Outcome:
The administration of anticoagulants after spinal surgery still remains controversial due to the risk of epidural hematoma and paraplegia. However, K.S. is 7 days post-op which greatly decreases this risk and the complications of not treating the newly diagnosed significant PE would have a higher mortality rate. Patients who survive the initial episode and who are able to receive appropriate treatment generally do well as K.S. is suspected to fully recover. It is recommended that K.S. also switch to a birth control method with a lower risk of subsequent blood clots.

Comments:
The prognosis of people with PE depends on many factors. First and perhaps most significant is the size and location of the clot. The bigger the clot and the larger the blood vessel that is blocked, the more serious the condition is. The outlook may be poor with big clots or clots blocking larger blood vessels. Some people may die immediately when a blood clot breaks loose and goes to the lung. Still others die in a short time period because of inability to get oxygen into the blood or from blood pressure collapse.

Case created by Kimberly Schuelke, 2011.