Tag Archives: Pulmonary Embolus

Anxiety Attack…

May 26, 2015

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This patient presented with the chief complaint of an “anxiety attack.”  They felt short of breath, onset after arguing with another person, and they had a history of panic attacks in the past.  Here’s what we found…

Saddle Embolus 1 Saddle embolus 2 Saddle embolus 3

This is a scary pathology that is on the differential of panic attack:  saddle pulmonary embolus.

“Saddle” refers to a main pulmonary artery involvement.  In the images above you can see a filling defect just as the main pulmonary artery branches off to the right and left sides (see red arrow below).

saddle-embolus-3 (edit)

Large main pulmonary emboli are life threatening diagnoses that can easily progress to sudden death.

History of present illness in this patient screamed panic disorder.  However, we had some clinical clues that altered the direction of the case:  hypoxia to the high 80s, tachycardia, and an EKG with a right axis.  On review of systems the patient said she had had vague calf pain over the last week.  Thus we ended up pursuing CT imaging as opposed to treating her “panic attack” with benzodiazepines…good call!

Author:  Russell Jones, MD

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“Doc I’m a little short of breath…”

July 9, 2013

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I had a man present the other day with dyspnea, mostly on exertion, minimal pleuritic chest pain.  He was hemodynamically stable while sitting in the gurney but would desaturate to the high 80s and become tachycardic with walking several feet.  He had a history of recently diagnosed multiple myeloma and was awaiting treatment initiation.  Here’s what we found on Chest CT:

Central PE 2Central PE 1

 

The chest CT shows a “saddle embolus.”  This is a pulmonary embolus that is very large and located in the proximal pulmonary artery before it bifurcates into the right and left pulmonary arterial tree.  This type of pulmonary embolus represents a large clot burden that can easily lead to hemodynamic instability and sudden death.  In fact, it was very suprising that this patient was so stable sitting in the gurney.  Initially he was reading a book on his tablet which I usually associate with no emergent pathology! 

This is a good time to review the indications for thrombolysis in pulmonary embolus:

  • Severe hypoxemia
  • Intractable hypotension
  • Large perfusion defect on ventilation-perfusion scans
  • Extensive embolic burden on computed tomography
  • Right ventricular dysfunction
  • Free-floating right atrial or ventricular thrombus
  • Patent foramen ovale
  • Cardiopulmonary resuscitation

These are all relative indications and it is important to weigh the risks of thrombolytics on a case-by-case basis.  There are no true indications for thrombolytics.  There are many widely accepted contraindications…I’ll leave it up to the reader to search for these. 

Author:  Russell Jones, MD

References:

1.  Tapson, VF.  Fibrinolytic (thrombolytic) therapy in acute pulmonary embolus and deep venous thrombosis.  www.uptodate.com.  Accessed 7/2013.

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