An 83-year-old female patient presented with sudden onset dyspnea and was found to have a large pulmonary embolism and deep vein thromboses. Her hospital course was complicated by massive hemoptysis during a procedure for the PE. She required intubation, bronchoscopy, and remained on ventilatory support for several days. Testing later found she had an inherited hypercoagulable condition. On awakening, she displayed possible neurological deficits that prompted head imaging.

1. Noon Conference
Carolyn Aldana
10/31/2018

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Choose your own adventure!
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YOU ARE A DOCTOR
You are a doctor. You
were forged in the
crucible of medical
school and have
emerged, a resident
physician. Your
journey has just
begun, and you have
been assigned to the
critical care unit. Your
first patient awaits.
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The Patient
83yoF with a history of HTN and dementia who
presented from SNF for sudden onset dyspnea,
found to be tachycardic to the 120s, hypotensive to
the 60s, and hypoxic to the 70s on RA, afebrile.
The hypotension resolves with 1L NS.
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The Patient
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PMH: Dementia with Parkinsonian features, HTN, HLD,
Prediabetes, Osteopenia
PSH: Appendectomy, oophorectomy/salpingectomy, shoulder
repair
Meds: ASA 81, enalapril, memantine, metoprolol, Vit D and
calcium, Miralax, vitamins, stool softener, Tylenol
Allergies: contrast dye, sulfa drugs
Social Hx: retired economist, lives in an ALF with her
husband, ambulatory with a walker, never smoker, no EtOH,
no drugs
Fam Hx: non contributory

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The Patient
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Physical Examination
General: Oriented to person only. Alert, resting in bed in NAD
Head: NC/AT
ENMT: external nares patent, OMM, no posterior exudate, inflammation
Neck: Supple, Normal ROM
Chest: Good air movement, coarse breath sounds, crackles anteriorly
CV: Rapid rate, no m/r/g
Abdomen: Non-distended. Bowel sounds present. Nontender to palpation
Extremities: No LE edema
Skin: No rashes, lesions, nodules on exposed skin
Neuro: Moving extremities spontaneously
Psych: Flat affect

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The Patient
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ED workup:
Labs: CBC, CMR, INR wnl. trop 0.246
EKG: nonspecific TWI, otherwise normal
CXR: essentially clear, mild pulmonary congestions
CTH: no acute intracranial abnormalities
Bedside echo: distended IVC

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PE?
You strongly suspect PE as the source of her
symptoms, so you start enoxaparin.
However, you need to clinch the diagnosis.
1) Order a CT-PA emergently
2) Order a V/Q scan
3) Order a CT-PA, but premedicate with prednisone
50 mg PO at 13, 7, and 1 hour prior, as well as
diphenhydramine 1 hour prior.
4) Order a CT-PA but premedicate with
methylprednisolone 40 mg IV at 5 and 1 hour prior,
as well as diphenhydramine 1 hour prior
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Contrast Allergy
■ The breakthrough reaction rate for 5-hour intravenous prophylaxis
was 2.5% (five of 202 patients; 95% confidence interval [CI]: 0.8%,
5.7%), which was noninferior to the 2.1% (13 of 626 patients, 95%
CI: 1.1%, 3.5%) rate for the 13-hour regimen when a 4.0%
noninferiority margin was used (P = .0181).
■ All breakthrough reactions were of equal or lesser severity than
were the index reactions (two severe, one moderate, one mild).
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10. © 2016 Virginia Mason Medical Center
Hypotension!!
The CT angiogram showed a large, central
pulmonary embolism. Leg dopplers also show
bilateral DVTs. Upon her return to the CCU, she
becomes hypotensive again.
On physical examination, blood pressure is 78/54
mm Hg, pulse rate is 120/min, and respiration rate
is 28/min. Oxygen saturation is 93% on 6 L/min of
oxygen through nasal cannula. Lungs are clear on
auscultation. Cardiac examination reveals a grade
2/6 systolic murmur above the left lower sternal
border. The second heart sound is persistently split.
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Hypotension!!
You think to yourself that it is fortunate that the
situation is almost exactly Pulm/Crit MKSAP 18
Question #85, which you have already done and
which helps guide your next move.
1) Add recombinant tissue plasminogen activator
2) Change to apixaban
3) Change to intravenous unfractionated heparin
infusion
4) Continue low-molecular-weight heparin
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MKSAP pearl:
“Treatment of patients with acute pulmonary
embolism with unfractionated heparin infusion
appears to be associated with increased risk of
adverse effect compared to LMWH administration.
The 2014 European Society of Cardiology guidelines
for diagnosis and management of pulmonary
embolism recommends LMWH or fondaparinux
rather than unfractionated heparin in
hemodynamically stable patients because they are
associated with a lower risk of heparin-induced
thrombocytopenia and major bleeding events.”
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13. © 2016 Virginia Mason Medical Center
The plot thickens
You call the IR doctor on
call. In the interim the
hypotension turns out to
have been a cuff error, but
there’s evidence of right
heart strain on the CT, so
he agrees to proceed with
EKOS catheter placement
and tPA.
Just after the groin
catheters are placed and
before tPA, she coughs.
You see a flash of red.
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Massive Hemoptysis! Oh my!
Blood pours out of her mouth and you
visually estimate it is more than 200 cc, so
technically massive hemoptysis. She
becomes obtunded and her BP is 64/42.
She desats to the 70s on 6L NC.
1) Continue the heparin gtt
2) Stop the heparin gtt
3) Stop the heparin gtt and give protamine sulfate
4) Stop the heparin gtt, give protamine sulfate,
and recombinant factor VIIa
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15. © 2016 Virginia Mason Medical Center
Did you guys see this picture in NEJM?
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In addition to reversing her
anticoagulation, you
assemble the team for
emergent intubation and
bronchoscopy.
The bronch shows clot
filling the right bronchial
tree, which is removed with
no further bleeding. There
is active bleeding on the
left with the beginnings of
clot formations.

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Positioning
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The attending decides to leave the
left side alone and plan to
rebronch in several hours after the
clot matures. She tells you to
make sure the patient is correctly
positioned in the interim.
You instantly know she means…
1) Trendelenberg
2) Left Lateral Decubitus
3) Right Lateral Decubitus
4) Prone

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Protect the non-bleeding lung
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The plot remains thick
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She undergoes a repeat bronchoscopy with
removal of a clot from her left bronchial tree, with
no further bleeding. However, her course is
complicated by shock, unclear if hemorrhagic or
distributive from sedation, and initially requires
pressors.
She remains sufficiently hypoxic that she requires
neuromuscular blockade and several days of
intubation.
An IVC filter is placed, and she is started back on
low intensity heparin.

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Detective Work
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While you preround, the patient’s daughter is at
bedside and asks why she got the PE in the first
place.
She has had no recent surgeries, recent travel,
known malignancies, immobilization, med changes,
history of miscarriages, or prior history of blood
clots. You offer to run some tests.
1) Antithrombin levels
2) Protein C and S levels
3) Lupus anticoagulant
4) Factor V Leiden

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Hypercoagulable Workup
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Weakness?
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The paralytics are stopped after about a day, and
sedation is stopped 3 days later. At that point, she
is noted to be awake but CAM+, and not following
commands reliably. Because of this, it is another
day before she is extubated. She remains lethargic
and confused. Sometimes the nurse wonders if she
might have right arm weakness on exam, but it is
inconsistent and difficult to elicit.
1) STAT CT head
2) 24 hour EEG
3) Non-pharmacologic delirium interventions
4) CTM

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Pontine Infarct
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23. © 2016 Virginia Mason Medical Center
References
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Bauer, K. A., MD. (2018, December 13). Evaluating adult with established venous thromboembolism for acquired and
inherited risk factors. Retrieved February 24, 2019, from https://www.uptodate.com/contents/evaluating-adult-patients-
with-established-venous-thromboembolism-for-acquired-and-inherited-risk-
factors?search=hypercoagulable%20workup&source=search_result&selectedTitle=1~150&usage_type=default&display
_rank=1
Ingbar, D. H., MD. (2017, May 24). Massive hemoptysis: Initial management. Retrieved February 24, 2019, from
https://www.uptodate.com/contents/evaluating-adult-patients-with-established-venous-thromboembolism-for-acquired-
and-inherited-risk-factors?search=hypercoagulable
workup&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Mervak, B. M., Cohan, R. H., Ellis, J. H., Khalatbari, S., Davenport, M. S. (2017). Intravenous corticosteroid
premedication administered 5 hours before CT compared with a traditional 13-hour oral regimen.
Radiology 2017; 285: 425–33.
Radchenko, C., Alraiyes, A. H., & Shojaee, S. (2017). A systematic approach to the management of massive
hemoptysis. Journal of thoracic disease, 9(Suppl 10), S1069-S1086.