Pulmonary Embolism
Patient Presentation:
A 65 year-old female, S.H. is post operative day number two after a right total knee replacement. After surgery the patient has experienced tremendous 10/10 pain, which has been largely unresponsive to oral narcotics. Due to her difficulties with her pain the patient has refused physical therapy and has been unable to get out of bed. During her morning nursing assessment, the patient complains of moderate chest discomfort with pain level 6/10, some shortness of breath, and quickly thereafter became diaphoretic. The patient’s past medical history includes: depression, anxiety attacks, GERD, and DVT after a previous left total knee replacement. Vital signs reveal: BP 152/82, HR 139, RR 26, T: 98.7, O2 sat on RA: 90%.
Differential List:
Acute myocardial infarction, pulmonary embolism, anxiety r/t increase in pain
Diagnosis:
Immediately a 12-lead ECG was ordered and performed revealing sinus tachycardia with ventricular rate of 139 beats per minute. STAT cardiac enzymes were ordered including troponin level which was WNL. CPK-MB was also within normal limits. Post operative joint replacement patients are typically placed on anticoagulant therapy. The patient has been placed on the warfarin protocol that began the night after surgery. Her pre-operative INR was 1.01. Her post-op day #2 INR was 1.2 after having received two doses of 5mg of coumadin. Her INR goal on the warfarin protocol was 2-3, so the patient was not yet therapeutic. The physician chose to immediately order a spiral CT arteriography, which revealed the presence of multiple small pulmonary emboli in branches of her right lower lobe. Other tests that are often ordered in cases of suspected PE include serum d-dimer and arterial blood gas. If the serum d-dimer is normal, a PE may be ruled out. ABGs results will typically show patients to have respiratory alkalosis due to hyperventilation.
Treatment:
For her treatment, oxygen was applied and anxiety levels reduced for pain with morphine 4mg IV push. The patient was not a candidate for thrombolytic therapy, but she was started on an intravenous heparin drip titrated per hospital protocol and started with a bolus. While on anticoagulant therapy, this will prevent future clotting while allowing the body to break up the clots on its own. The patient was also ordered for a venous Doppler ultrasound of bilateral lower extremities to assess for any previously undetected DVTs. The patient will require close observation, frequent vital signs, and frequent serum coagulation samples for heparin titration. Warfarin will also be resumed at this time.
Outcome:
This patient may be a candidate for the placement of an inferior vena cava filter once she is stabilized based on her past history of DVT and the presence of multiple pulmonary emboli. Her warfarin therapy will be continued for three to six months.
Case created by Shannan Henry, 2011.