Clot versus Bleeding-- The Dilema

This is a great case! I hope you find this interesting. As usual, it has been anonymised.

A male patient of 55 had recently been on a short holiday to Hokaido and had been well during that time.

On coming back to central Japan, he was feeling unwell with a sore throat and was diagnosed with influenza. Unfortunately, he fell over sustained a contusion to the right knee leading to severe bruising and a swollen, painful knee.

He was bed bound for two days and slept most of the time.

On the night of admission, the patient got up from bed and he was seen to slowly slump to the floor with a loss of consciousness for 1 minute. The patient's right arm was seen to move erratically for up to 20 seconds similar to a seizure. There was no tongue biting and no urinary incontinence. The patient awoke after a few minutes and his consciousness was clear.

On arrival to hospital, the patient was noticed to have low oxygen saturations.

Examination revealed mild fever 37.8, pulse 70 min and regular, BP120/80 (lying), RR 24/min. SpO2 was 80%, Patient was over weight.

Red throat.

CVS- JVP- not raised. Sounds 1 + 2 normal. No mumurs.

RESP- mild right sided crackles that mostly cleared on coughing.

ABDO: Within normal limits.

NEURO: NAD

Right Lower Limb: Swollen, severely bruised. Right patella was painful and easy to move. There was a mild patella tap consistent with a probable intra-articular bleed.

The left leg was normal.

ABG: revealed normal pH but severe Hypoxaemia (PaO2: 52mmHg).

CXR: Nothing focal. No pneumonia or other obvious lung pathology.

ECG: NAD

Bloods: Slight neutrophilia and raised CRP.

Knee Xray: No obvious fracture seen.

CT head: NAD

In view of the collapse, and profound hypoxaemia with the history of leg injury and immobilisation plus an overweight body habitus, Pulmonary Embolism was suspected.

A Spiral CT was performed which showed thrombus in the right and left pulmonary vessels. A perfusion scinitigraphic scan was performed which showed multiple small perfusion defects consistent with small PEs seen on the spiral CT.

Doppler scans of the lower limbs showed no evidence of thrombus.

Echocardiogram revealed a relatively normal pulmonary artery pressure of 26mmHg but the Right Ventricle was slightly distended with 1st degree Tricuspid Regurgitation. Ejection fraction was 68%.

Hence, the physicians had made the great diagnosis of PE.

The patient was eventually commenced on heparin treatment by his physicians.

The patient's limb remained unchanged and the heparin was successful.

An excellent comment I received from a senior doctor suggested that in such cases heparin should always be commenced even if the patient's limb becomes compromised whilst treating PE to save the patient's life.

That is a tough decision to take for any doctor and is the balance between treating the patient but also trying to do no harm to your patient.

Do you agree with this approach?

What would you do in such a situation?

Without your comments other doctors or students are unable to learn so please give your opinion on this blog.