Critical Care Medicine-Pulmonary Disorders>>>>>Thromboembolic Disease and Hemoptysis
Question 1#

A 55-year-old female with a history of renal cell carcinoma with metastases to the spine is scheduled for a spinal separation procedure to facilitate radiation therapy. The surgical procedure was uneventful. Following skin closure, there was a sudden drop in oxygen saturation to 86% with an increase in heart rate to 124/min and blood pressure of 85/41 mm Hg. The peak airway pressure was 25 cm H2O and the ETCO2 is 15 mm Hg. 100% oxygen was administered and the patient was started on an epinephrine infusion to support hemodynamics.

Which of the following statements is LEAST likely to be true if you are considering a diagnosis of pulmonary embolism in this patient? 

A. S1Q3T3 on ECG is seen in less than 20% of the patients
B. The VQ mismatch is due to an increase in dead space ventilation
C. Hemoptysis is an uncommon presenting symptom
D. Intravenous heparin infusion is the treatment of choice in this patient

Correct Answer is D


Correct Answer: D

Advancing age, immobilization, and a diagnosis of cancer confer an increased risk of deep vein thrombosis and pulmonary embolism (PE). Contrast-enhanced chest CT scan is the most commonly used modality to confirm the diagnosis of a PE. As PE represents a perfusion defect, there is an increase in dead space ventilation in these patients. In addition to initial stabilization, volume infusion, and vasopressor therapy, systemic anticoagulation is initiated in most patients with a PE as long as there are no contraindications. Recent surgery, especially in closed spaces like brain/spinal cord, active bleeding, and malignant hypertension are considered contraindications for systemic anticoagulation. Thrombolytic therapy is reserved for patients with PE who present with hemodynamic instability. Although it could rapidly restore pulmonary circulation and improve right ventricular function, it confers a higher risk of bleeding. Catheter-directed thrombolysis can be considered in patients in whom the risk of bleeding with systemic therapy outweighs the benefits. 


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