Q&A Medicine>>>>>Pulmonology
Question 57#

A 68-year-old man undergoes a left hip replacement and is recovering in the hospital afterward. As he stands up to walk with the physical therapist, he suddenly collapses. He undergoes initial resuscitation and is intubated, but he remains hypotensive despite heavy fluid resuscitation. The patient is tachycardic, but the rest of his cardiac and pulmonary examinations are normal. IV heparin is started and a CT angiogram is performed (Figure below).

What is the next step in management?

a. Coronary angiography
b. Start IV enoxaparin
c. Start IV alteplase
d. Thrombectomy
e. Placement of an inferior vena cava (IVC) filter

Correct Answer is D

Comment:

Thrombectomy. This patient experienced a massive pulmonary embolism, and a “saddle embolus” affecting the pulmonary trunk and arteries is seen on the CT angiogram. Patients undergoing surgical procedures (especially orthopedic surgery) are at an increased risk of clot formation and pulmonary embolism. The initial management of a pulmonary embolism depends on whether the patient is stable or unstable. If the patient is stable and there is a high suspicion for pulmonary embolism, then IV anticoagulation should be started during the workup (e.g., heparin, enoxaparin, fondaparinux, etc.). If a patient has a DVT discovered but is asymptomatic, then the answer is still IV anticoagulation. If the patient is unstable, then they need to be resuscitated and stabilized with ventilation, blood pressure support, and empiric anticoagulation (as long as pulmonary embolism is highly suspected and there are no serious contraindications). (C) Persistent hypotension is an indication for fibrinolytic therapy (alteplase); however, recent surgery within 10 days is a contraindication to this therapy. Other contraindications to fibrinolytics include the presence of an intracranial tumor, recent intracranial surgery or trauma, previous hemorrhagic stroke (or nonhemorrhagic stroke in the past 2 months), internal bleeding within the past 6 months, bleeding diathesis, severe hypertension, and a platelet count <100,000/mm3 . Thrombectomy is an option if the patient fails fibrinolytic therapy or has a contraindication to systemic fibrinolysis, and it can be performed surgically or with a catheter. This is the best option for this hemodynamically unstable patient that has a contraindication to fibrinolysis.

(A) The immediate concern is the massive pulmonary embolism on CT, not diagnosing coronary artery disease. (B) Though the patient had recent surgery and therefore is at a higher risk of bleeding, IV anticoagulation is still warranted and the benefits outweigh the risks. Enoxaparin is preferred over heparin by some; however, heparin has already been started and only one agent should be used. (E) An IVC filter is a good option for patients with a confirmed DVT or pulmonary embolism that have a contraindication to anticoagulation (failure of previous anticoagulation, serious bleeding with previous anticoagulation, or high bleeding risk; although recent surgery is a risk factor for bleeding, high risk typically means there are 2 or more risk factors). However, this is not a good option since it will prevent future pulmonary emboli but will not address the current life-threatening embolism!