Not just a PE

aka Pulmonary Puzzler 002

This 25 year old female presented with worsening breathless. She has no previous medical problems. Her Chest X-ray is shown below.

CXR Pulmonary Puzzler 002

Questions

Q1.Describe the chest X-ray findings.

Answer and interpretation

This chest X-ray is normal (or so the radiologist says)


The pulse oximeter reads 90% so you decide to perform a blood gas:


Q2. What does the blood gas show?

Answer and interpretation
  • Firstly, the pulse oximeter is accurate!
  • Secondly, the patient is sick.
  • Thirdly, the patient has a marked respiratory alkalosis (i.e. she is breathing hard).
  • Fourthly, the A-a gradient is markedly widened.

After careful consideration of the diagnostic possibilities you decide to perform a CTPA:


Q3. What does the CTPA demonstrate?

Answer and interpretation

Surprise, surprise… a pulmonary embolism (if someone shows you a CTPA and asks you what it shows this is usually the correct answer).
Of particular note, the pulmonary trunk is larger than the aorta.   This is often indicates the presence of elevated right ventricular systolic pressure.


Before anticoagulating the patient you review the blood tests:


Q4. Describe the significant abnormalities. What is the diagnosis?

Answer and interpretation
  • Thrombocytopenia is significant (given the need to anti-coagulate).
  • The presence of an elevated APPT that corrects with high phospholipid reagent is seen in antiphospholipid syndrome and thrombocytopenia is also a feature of this condition.

Q5. How would you treat this patient? (by the way the answer is not to ask someone else from another speciality what to do)

Answer and interpretation

The conundrum here is what to do about a life threatening pulmonary embolism is a patient with no platelets.  One option is to treat the low platelets so that you can anticoagulate the patient safely. 

Thrombocytopenia often gets better with steroids in this condition.


While waiting for the steroids to work you need to make sure that patient doesn’t drop dead from a further pulmonary embolism so you order an ultrasound of the legs to assess the situation further.


Q5. What does the ultrasound demonstrate?

Answer and interpretation

This ultrasound scan shows a normal vein which disappears with compression.

The other leg looks like this because there is a DVT.


Q6. What is this?

Answer and interpretation

An IVC filter to stop the DVT from the leg travelling to the pulmonary artery while waiting for the steroids to kick in.


Q7. Describe the ECG

Answer and interpretation

This ECG demonstrates right ventricular strain with T wave inversion in the anterior leads.

The echo report confirms the presence of right ventricular strain:


References

Pulmonary Puzzler-LITFL 700

CLINICAL CASES

Pulmonary Puzzler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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