Pulmonary Embolus
Patient Presentation:
S.M., a 77-year-old male was admitted to the unit with an inter-trochanteric fracture of the left femur after falling at home three days ago. He is awaiting surgery, which is planned for tomorrow morning. Since the fall, he has been on strict bed rest due to the nature of the fracture. S.M. has Past Medical History of GERD, prostate cancer, anxiety, and depression. He pressed the call bell asking for help while anxious and complained that he “just didn’t feel right”. Upon assessment, the RN noted the patient to be diaphoretic, anxious, and speaking quickly and forced with short breaths. His VS were taken and noted: BP 136/82, P 126, RR 30, O2 Sat of 90% on room air, improving to 92% with 3L O2 nasal cannula, temp 38.1C. Lung sounds clear to auscultate bilaterally, heart rhythm is tachycardic but regular. His bilateral lower extremities were warm and pink but the LLE was swollen, warm, externally rotated (consistent with his fracture).
Differential Diagnosis:
Pre-op anxiety, pulmonary embolism, pneumonia, alcohol withdrawal
Labs/Tests:
A stat EKG ordered shows sinus tachycardia but the patient’s tachypnea and hypoxemia warranted further investigation with a CXR. The CXR was clear with mild atelectasis in left lower lobe. A CT with IV contrast was ordered next and it was positive for left segmental pulmonary embolus (PE). Note: a V/Q scan would have been ordered if the patient had an allergy to iodine/contrast or had Cr over 1.3
Labs drawn included:
CBC: WBC: 8, Hgb: 30, Hct: 8.7
CMP: Na+: 137, K+: 3.9, Ca++: 8.2, Phos: 4.9, Mg: 2.0, BUN: 16, Cr: 0.8
D-dimer Assay (ELISA) not collected: it has high negative predictive value to rule out PE but has low specificity and is expensive for our lab to run.
Treatment:
S.M. was transferred to the step-down unit for monitoring after the CT was positive for PE. There he was placed on a heart monitor and started on anticoagulants: enoxaparin (Lovenox®) at therapeutic dose 1mg/kg SC BID (80mg BID) and warfarin (Coumadin®) PO Daily. The MD ordered this as a “Loxenox Bridge” until S.M.’s INR was therapeutic (INR goal 2-3) for two days after which he could discontinue Lovenox® injections and just take Coumadin®. He was given 3 liter O2 per NC for his low O2 saturation in the meantime and remained on bed rest.
Outcome:
Pulmonary Embolism prognosis depends on the amount and area of lung affected and how quickly it is noted. Fortunately, S.M.’s PE was treated effectively and promptly. S.M. will need to continue Coumadin® and maintain an INR of 2-3 for three to six months. While taking Coumadin®, S.M. needs to be advised to maintain consistent intake of foods high in Vitamin K including green leafy vegetables and some oils as inconsistent amounts can skew the INR result. He should also be advised to use an electric razor and beware of his risk for falls/trauma which could lead to bleeding while on anti-coagulants. S.M. was taken off the OR list for the next day and Cardiology was consulted to evaluate the need for an IVC filter placement prior to surgical repair of the femur fracture.
Case created by Sarah Metz, 2011.