Discussion
Pulmonary embolus (PE) refers to the obstruction of the pulmonary artery
or one of its branches by material such as thrombus, tumor, air, or fat
that originated elsewhere in the body. It can be acute, subacute and
chronic based on the timeline of its presentation. It is also classified
based on the presence or absence of hemodynamic stability, which is
associated with right ventricular strain which is also called massive or
high-risk PE.
PE has a wide variety of presenting features, ranging from no symptoms
to shock or sudden death. The most common presenting symptom is dyspnea
followed by pleuritic chest pain, cough, and symptoms of deep venous
thrombosis such as lower extremity pain, swelling and tenderness.
Hemoptysis is an unusual presenting symptom. Rarely do patients present
with shock, arrhythmia, or syncope. Diagnosis usually starts with a high
index of clinical suspicion along with elevated D-Dimer and imaging
includes computed tomographic pulmonary angiography and less commonly,
ventilation perfusion scanning or other imaging modalities. For patients
who are hemodynamically unstable and in whom definitive imaging is
unsafe, bedside echocardiography or venous compression ultrasound may be
used to obtain a presumptive diagnosis of PE to justify the
administration of potentially life-saving therapies such as TPA.
In this case, the patient presented to a rural hospital with syncope
with subsequent testing showing large bilateral pulmonary embolism.
Hence, she was started on full dose Lovenox. Despite having normal vital
signs and being on anticoagulation, she deteriorated overnight with
recurrent episodes of syncope and hypotension manifested by drops in
systolic blood pressure to more than 40 mmhg. Due to limited abilities
in a rural setting, the decision was made to transfer to a facility
capable of catheter directed thrombolysis. Unfortunately, following her
transfer she was pronounced dead.
Therefore, the distinction between hemodynamically stable and unstable
PE is important because patients with hemodynamically unstable PE are
more likely to die from obstructive shock as a result of severe right
ventricular failure. Syncope associated pulmonary embolism can be fatal
and attributed to rapidly decreasing cardiac output if not treated
emergently.