Case Study: Acute PE in a 61 y/o Male

Case Study: Acute PE in a 61 y/o Male

A 61 y/o male admitted for upper gastrointestinal bleeding from peptic ulcer disease complains of acute onset of shortness of breath and was found to have a saddle right lung PE by CT.

What is the most appropriate treatment?

  1. Pulmonary embolectomy
  2. Oral anticoagulation
  3. Thrombolytics
  4. IV Heparin (bolus the drip)
  5. Inferior vena cava filter

When CTA confirms an acute PE, anticoagulant is the key treatment.  Almost always. What if the patient is super sick?  Clinical presentation is severe enough to warrant thrombolysis. BUT… this is super rare.  Really rare.  I have never heard of it clinically.

A closer look

An inferior vena cava filter is an appropriate alternative for patients with confirmed acute PE who have a high risk for bleeding, complications of anticoagulation, recurrent PE despite therapeutic anticoagulation, or hemodynamic or respiratory compromise that is severe enough that another PE may be lethal.  This is the answer my question was headed toward. BUT… I asked a bad question.  So, we are going to accept embolectomy.

For patients with acute PE where thrombolysis is indicated, but who fail thrombolysis or have contraindications to thrombolysis, catheter or surgical embolectomy is suggested.  BUT… this is rarer then thrombolysis.  ICU stuff.

Conclusion

Students, it’s either anticoagulation (99%) or IVF filter (1%), in my clinical experience.

I love sharing case studies like this as learning opportunities for my fellow medical providers. I work lessons and case studies like this into all our CME products – check out our shop to find the best option for you (we’re also giving away some great gift cards, iPads and Surfaces for free with many CME products).

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John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.
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