CCS Case: Pulmonary Embolism

Case: Pulmonary Embolism

Clinical Setup

• Presentation: 45-year-old female with sudden pleuritic chest pain, dyspnea, tachycardia (HR 118), tachypnea, SpO2 91% on room air, 3 days after a long-haul flight. Unilateral leg swelling noted.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access, Normal saline 0.9% IV @ 100 mL/hr.
   • Oxygen via nasal cannula, titrate to SpO2 > 94%.
2. Focused Exam (Minute 1–2):
   • Lung exam, Heart exam (accentuated P2, tachycardia), lower extremity exam (Homan’s not relied upon; note swelling, calf asymmetry).
3. Diagnostics (Minute 2–5):
   • ECG 12-lead stat (sinus tachycardia; S1Q3T3 if present), CBC, BMP, PT/INR, PTT.
   • ABG stat, troponin, BNP (risk stratification).
   • CT angiography of the chest (PE protocol) stat.
   • Bilateral lower extremity duplex ultrasound.
4. Therapeutics & Consultation (Minute 5–12):
   • Heparin IV bolus + infusion (or weight-based LMWH such as Enoxaparin) — start promptly once PE suspected and bleeding risk acceptable.
   • If massive PE with hypotension: consider thrombolysis per protocol and ICU-level care.
   • Advance clock 30 min, re-examine vitals and respiratory status.
5. Disposition (Minute 12–15):
   • Admit to inpatient ward; transfer to ICU if hypotensive, hypoxic despite O2, or RV strain on imaging.
   • Transition to oral anticoagulant (e.g., Apixaban or Rivaroxaban) for discharge planning when stable.
6. Final 2 Minutes:
   • Counsel on anticoagulant compliance, bleeding precautions, compression stockings, early ambulation, avoid prolonged immobility.
   • Schedule hematology/primary care follow-up; arrange duration-of-therapy plan (minimum 3 months for provoked PE).