Sunday, 22 November 2009
Pulmonary Emboli, clot on the lung - learning points
This picture shows a pulmonary embolism or clot blocking off an artery in the lungs. It causes a sudden shock or collapse, where the patient has sudden severe pain in the chest, rapid breathing and a rapid pulse. He or she feels extremely anxious, sweaty and as though they might die.
You need to call a doctor or ambulance urgently
Pulmonary embolus (embolism or embolis) is a clot
The case outlined in the previous post has a number of learning points
This is a fit individual, apart from his chronic chest complaint. He has been in hospital once only, there is no history of diabetes or other illness, and he is not thin, indeed the notes say he had put on three stone in weight prior to his admission.
BJ "collapses" several times. Both in the October before his operation and after his operation. After a couple of days, he is back on his feet as though nothing had happened.
There are not many causes for this type of collapse. We are looking for something that comes on suddenly and gets better quickly. Sudden disturbances are always due to either a problem with
1 - the nervous system - the brain or spinal cord, such as epilepsy
2 - the heart and circulation, such as an abnormal rythm or a clot on the lung which blocks off a large part of the blood vessels to the lungs, which is another name for pulmonary emboli. Over time this damages the lungs, you get high blood pressure in the lungs, and the lungs do not work so well.
Clots in the lungs comes usually from a DVT. BR had had DVTs in the past. He did not move around a lot, and during surgery he would have been at extra risk. He was given white stockings to reduce the risk but this does not prevent a DVT especially in someone at high risk
One notable feature of a pulmonary embolus (the different endings are latin ;-)
is the anxiety and feelings of panic that come with the damage to the lungs. The person feels like they are going to die.
Pulmonary emboli are hard to diagnose, unless you keep your eyes open
There is no direct test - although changes in the concentration of oxygen and carbon dioxide in the blood indicate there is likely to have been a clot.
Chest Xrays usually look normal as do ECGs, although the pulse rate is usually fast.
Ventilation perfusion scans need to be done almost immediately - these show the blood flow in the lungs. These scans show large pulmonary emboli but miss small ones
The single most important point in diagnosing a pulmonary emboli is the history - short, often repeated collapses from which the person recovers quickly over the next two days
Why was this not diagnosed in BR's case? Because different doctors saw him. No one works 108 hours on the trot, so they do not see the condition emerge and they do not see the pattern of pulmonary embolus over time. Each doctor comes into the hospital or clinic and only sees a snap shot of the patient in time. This is like trying to understand a film like Slum Dog Millionaire from a series of photographs. You need to watch the film to know what is going on. You need to watch the patient over time to understand what is happening
If you have any questions, please email me at firstname.lastname@example.org, I am happy to take questions
Copyright (c) Dr. Liz Miller
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