Multiple PE's

[fma08]

Had a patient the other day, transferred due to "multiple PE's in all lobes". Radiologist said he had never seen such a definitive positive for PE's. Now I know what a PE is, lifestyle and risk factors for one, but I have never had a patient with so many at once and am curious to know if anyone knows a reason for such an occurrence. Bad luck? Something major going on? No prior history in the patient for any medical problems... Either having a major brain fart or just stumped on this one. I feel like there is something more going on with this patient than it seems.

 

[Aidey]

Almost impossible to tell without knowing his social history, family history and lab work.

 

[blindsideflank]

Sepsis, DIC?
Genetic coagulopathies?
Malignancies?
Labs would be nice to see.

No recent blood transfusions or surgeries?

 

[fma08]

No medical or surgical history, pt. never had major illness, not on medications, no surgeries, no recent travel. Labs were essentially normal as I recall except for low hemoglobin (9ish), hematocrit was off too, can't remember exact value, and positive D-Dimer (obviously). 2 brothers who both had PEs.

 

[Anjel]

I saw a patient like that once.

Except mine was really sick.

He was on coumadin and fell and hit his head. He had an intracranial hemmorhage and had to be taken off the coumadin.

He came into the ER a week later with multiple PEs. His pulse ox was at like 78%.

He was RSI'd, put on a ventilator, and eventually died.

I asked the doc why it happened so fast and why it was so much. He said it was the sudden change in Coumadin.

So there was a reason for mine.

 

[Aidey]

No medical or surgical history, pt. never had major illness, not on medications, no surgeries, no recent travel. Labs were essentially normal as I recall except for low hemoglobin (9ish), hematocrit was off too, can't remember exact value, and positive D-Dimer (obviously). 2 brothers who both had PEs.

So could be a genetic coagulopathy.

However, when I said social history and lab work I was referring to stuff way beyond what you could likely remember. Weight, diet, recent weight loss/gain, recent diet changes, ever a smoker; along with lab values that may or may not have even been run, Vit K level, PT/INR, aPTT, along with about 10 other tests I can't remember right now.

 

[fma08]

Mid 60s female. Obese (250lbs). Assuming diet was similar to that of the area (lots of old Scandinavian farming families). Non-smoker. No recent weight loss/gain. And the labs you mentioned I don't recall seeing so I'm guessing they weren't run until after our transfer to the higher level of care hospital.

 

[Aidey]

Still doesn't help unless you happened happened to ask her about her leafy green vegetable intake.

My point is that in order for anyone to actually be able to tell you with any certainty why she had so many PEs there is a lot of minutiae that has to be sorted out first.

 

[fma08]

Gotcha. Was just looking to see if there were a few things that usually cause someone to develop a bunch at once. I was quite surprised as I hadn't seen or heard of someone who had so many at one time.

 

[AnthonyM83]

Still doesn't help unless you happened happened to ask her about her leafy green vegetable intake.

My point is that in order for anyone to actually be able to tell you with any certainty why she had so many PEs there is a lot of minutiae that has to be sorted out first.

I'm sure you could elaborate on possible theories without having an exact profile for this patient (which we're unlikely to get).

AKA Without further information, what might be some possible reasons for multiple PE's in a patient with no known medical history, allergies, meds?

 

[JPINFV]

Another thing to remember is just because a patient doesn't have a history of a disease doesn't mean that they don't have it.

 

[VFlutter]

Another thing to remember is just because a patient doesn't have a history of a disease doesn't mean that they don't have it.

Very true.
"Sir, do you a history of hypertension" - "Nope"
"Your BP is 200/100" - "Oh ya it's been high for years"

 

[JPINFV]

Very true.
"Sir, do you a history of hypertension" - "Nope"
"Your BP is 200/100" - "Oh ya it's been high for years"

I was going more for the "you can't have a history of a disease before you're diagnosed with it."

 

[KellyBracket]

Had a patient the other day, transferred due to "multiple PE's in all lobes". ... am curious to know if anyone knows a reason for such an occurrence. Bad luck? Something major going on? No prior history in the patient for any medical problems...

This isn't meant to sound flippant, but the answer in medicine is almost always "bad luck." There are so many risk factors for a given disease, but they usually only incompletetly address the development of a disease.

The classic example of this is heart disease - plenty of non-smoking vegan athletes get heart attacks. That's why you can't rely on a checklists of risk factors to diagnose a STEMI.

Another example of this is breast cancer. There's a lot of discussion about genetics, diet, exercise, etc, but most breast cancer occurs in people without significant risk factors.

The only time I can feel certain about the etiology of a problem is when I caused it: "The pneumothorax? Yeah, that's all me. Tough central line..."

 

[usalsfyre]

Iatrogenisis, medicine's way of keeping you humble.

 

[jwk]

No medical or surgical history, pt. never had major illness, not on medications, no surgeries, no recent travel. Labs were essentially normal as I recall except for low hemoglobin (9ish), hematocrit was off too, can't remember exact value, and positive D-Dimer (obviously). 2 brothers who both had PEs.

Problem #1 - your patient is morbidly obese - that in and of itself is a problematic medical history.

Problem #2 - 60 y/o morbidly obese patients are rarely as healthy as you describe.

Problem #3 - 60 y/o morbidly obese patients are frequently couch potatoes, a classic setup for PE.

Problem #4 - A patient with a Hgb of 9 is not healthy. There is a reason they have a low hemoglobin. Could be a GI bleed, could be cancer, could be any number of things, none of which lead to a diagnosis of "healthy".

As far as the PE - this is what some would call a "shower of clots" or a "shower of emboli". A bunch of clots all busting loose, or a big clot that breaks up along the way, and the little clots just go every which way. Hey, it could be worse - they could have all held together as one giant clot and formed a big saddle embolus that occluded the PA in it's entirety and killed her on the spot.

 

[fma08]

Obviously the patient isn't healthy now, otherwise we wouldn't have transported and her vasculature wouldn't be filled with clots. Doesn't take a genius to see that.

I guess using the term morbidly was a bit excessive.

And yes, I did stay awake in school when we talked about risk factors.

My question was, why so many all of a sudden in a patient with an, otherwise, unremarkable (better medical term for you?) history?

As pointed out above, I'm just looking for a few, common/possible suggestions. It's not rocket science.

Those of you who have answered my question without thoroughly dissecting the post of a guy who's been on call for several days in a row, thanks for your help.

 

[VFlutter]

Obviously the patient isn't healthy now, otherwise we wouldn't have transported and her vasculature wouldn't be filled with clots. Doesn't take a genius to see that.

I guess using the term morbidly was a bit excessive.

And yes, I did stay awake in school when we talked about risk factors.

My question was, why so many all of a sudden in a patient with an, otherwise, unremarkable (better medical term for you?) history?

As pointed out above, I'm just looking for a few, common/possible suggestions. It's not rocket science.

Those of you who have answered my question without thoroughly dissecting the post of a guy who's been on call for several days in a row, thanks for your help.

If it is not rocket science then why can you not figure it out yourself? :glare:

Anyway, a quick online search....

"Generally, the smaller the embolus, the less severe the effects will be since a smaller percentage of lung volume will be affected by the blockage of a smaller pulmonary vessel. But often there are a number of emboli released at once or over time leading to a "shower" of emboli that can cause multiple blockages to one or both lungs. These multiple blockages can be as severe as one larger blockage resulting in a higher percentage of total lung function being lost."

As mentioned before there are various reasons why a person would develop numerous PEs. Could be an acute condition creating multiple emboli, a large clot that broke up, or a chronic condition that accumulated clots over time until they reached enough blockages to create symptoms.

Maybe she is on a 100% green leafy diet and likes to lay in bed 24 hours a day..... Who knows

 

[we talking bout practice]

I had a young man (20-30) paralized from the neck down, had flown from France to Vancouver to New Brunswick in 48 hours or so, and was a solid 350lbs. He was textbook p.e and he was found to have apx 13 blockages in the lungs all over.

 

[jwk]

Obviously the patient isn't healthy now, otherwise we wouldn't have transported and her vasculature wouldn't be filled with clots. Doesn't take a genius to see that.

I guess using the term morbidly was a bit excessive.

And yes, I did stay awake in school when we talked about risk factors.

My question was, why so many all of a sudden in a patient with an, otherwise, unremarkable (better medical term for you?) history?

As pointed out above, I'm just looking for a few, common/possible suggestions. It's not rocket science.

Those of you who have answered my question without thoroughly dissecting the post of a guy who's been on call for several days in a row, thanks for your help.

Dude, no offense intended here. I tried to answer your question in my last paragraph.

As far as the PE - this is what some would call a "shower of clots" or a "shower of emboli". A bunch of clots all busting loose, or a big clot that breaks up along the way, and the little clots just go every which way. Hey, it could be worse - they could have all held together as one giant clot and formed a big saddle embolus that occluded the PA in it's entirety and killed her on the spot.​

As I also tried to point out, your patient isn't healthy, nor is her history unremarkable. Morbidly obesity with a Hgb of 9 is not an unremarkable history nor the picture of health. Maybe the patient is the type that never sees a doctor. My mother-in-law never had cancer until her doctor told her she had it (although her colon cancer had likely been present for >5 years).

One of my first calls in St. Louis Co. years ago was a 22 y/o female. Her history to most would be unremarkable. We got called by her roommate who found her on the floor gasping for air. Turns out she had a massive PE. Her only history? She used oral contraceptives and smoked, which we knew even 30 years ago was a deadly combination.

There are dozens of causes and reasons that patients develop pulmonary emboli - sedentary lifestyle (often accompanies morbid obesity), lying around too much after surgery (that's why total hip/total knee patients are ambulated the day of surgery), coagulopathies of various sorts, hypercoagulable states from chemotherapy, not taking coumadin or other anticoagulants appropriately, hx of atrial fib, DIC, etc. There is nothing in particular that causes more clots or larger clots - they just form somewhere, attach to a vessel wall or lurk in a little corner of the heart, and occasionally bust loose. If they're big enough, or enough of them, they're very bad news.