patient death from PE

Nascar nurse, ASN, RN · Feb 8, 2012

Why you...! ::shaking you ferociously::

First time it was assumed to be birth control related. During that 13 year span, my father and my aunt (his sister) also had clots. Dr. tested them and showed positive for Factor V for both of them. They wanted to test me after my most recent clot 1 1/2 years ago but I refused. It is a pretty safe bet that I am also positive & I'm on coumadin for life now. Why label myself with this and have future problems with insurance denials.

To all of you; if it brings any comfort to you - I have thought a lot about this. I am 45 years old and have already watched way to many people from 20-50 years old die of cancer. They suffered horribly. I don't want to die young at all - but if it was meant to be I'll take a PE anyday over what I have watched some others suffer for years with.

Esme12, ASN, BSN, RN · Feb 8, 2012

thank u allactually was a male patient with no clot risk factors we knew ofhe had had a spontaneous pneumo three weeks previously and a NSTEMI however and had COPDso when he presented with tachycardia tachypnea and chest pain after ruling out another pneumo they started treating him as if he was having a COPD exacerbationAfter placing him on Bipap he started bradying down turned pale then purple and we ended up coding him without success

That is a sick 20 year old......spontaneous oneumo 3 weeks prior and a history of a MI with COPD.......not a healthy specimen. Either he had a genetic issue of I think of cocaine or crystal meth. One of the main causes of pulseless electrical activity is P.E.

DookieMeisterRN · Feb 8, 2012

Was helping with a pt about 15 yrs ago, not a nurse at that time yet. Pt was tachypneic, dypsneic and his nurse thought it was an anxiety attack. It was an abdominal post op in early 70's like 4 days post op and pt thought he would feel better if he sat up in a chair. I remember that moment clearly, asking his nurse "are you sure that's a good idea"? As soon as we stood him up he was gone. At that same moment the charge nurse stuck her head in the room and said 'lets get him to the unit, they've cleared a bed'. Before the days of rapid response teams I witnessed a lot more codes.

Advanced Practice Columnist / Guide · Feb 8, 2012

We all know based on our past patient encounters that PE's can be deadly. However, as providers and healthcare professionals, it is not typical to invoke the cause of a patient's death as a case of a possible PE without having formed an organized train of thought leading us to be convinced that indeed PE was the likely culprit. A major concept in explaining the occurrence of vascular thrombosis and embolisms is the Virchow's Triad. This triad is often invoked when figuring out if a patient is at risk for a venous or arterial clot. It identifies three processes (hence, triad) that leads to clot formation: Venous Stasis (i.e., prolonged immobility, immobilization due to surgery), Endothelial Injury (i.e., shear stress, HTN), and Hypercoagulable States (i.e., increased blood viscosity caused by oral contraceptives, tobacco use, cancers, inherited blood disorders). Patients who present with a DVT and/or PE typically have risk factors that fall into one or more causes in the triad.

Suspicion of a PE in patients who never underwent the gold standard of diagnostic tests which is a Spiral CT with IV contrast is still perfectly acceptable. Aside from the risk factors in the triad, cues that can point to the possibility of a PE include an elevated D-dimer (>500) which is present in over 90% of patients with a PE, and is normal in about 40-68% of patients without a PE. D-dimer is not useful in patients who are post-op, post trauma, has cancer, or in DIC. Hypoxemia is believed as a common finding in PE though there are case reports of patients with PE who have normal sats and pO2. The presence of a DVT in the UE and LE raises suspicion of a PE in symptomatic patients. Finally, a finding of RV strain or RV dysfunction on an echocardiogram can also point to the possibility of a PE. I would look back in your patient's ED course and figure out if these were found in this patient.

nerdtonurse?, BSN, RN · Feb 8, 2012

I've seen people who came in for shortness of breath end up dying from a PE -- one person was known to be non-compliant with her coumadin, because she didn't like having to drive in from the country to get the blood tests, so she just stopped taking it. She had a lot of reason to be on coumadin -- afib, morbid obesity, PVD, used one of those scooters to get around, very sedentary, hx. of breast CA, COPD and smoked like a freight train. Came in with what they thought was fluid overload/COPD exacerbation AGAIN (frequent flyer, treated all of us like garbage), came upstairs to us, turned completely purple as we moved her from the gurney to the bed, flash edema started pouring out of her mouth and nose. We worked on her for over an hour, never got a shockable rhythm. Family wanted an autopsy, hubby was sure we'd "done something" to kill her. The doc who did the autopsy came by to tell us that her lungs looked like they'd been hit by a shotgun blast full of blood clots - worst he'd ever seen, even had them in the L vent in the heart, so she was ready to MI or stroke out, if the PE hadn't gotten her. She never made it to 40.

I hate coding people younger than I am.

Perpetual Student · Feb 8, 2012

Yeah, that's a nasty history for a 20-something. I wager whatever led him to having a prior MI and COPD at such a young age contributed to his developing a PE.

There was a patient who was POD 1 or 2 from an orthopedic surgery up working with PT when she c/o not feeling well. She ended up dying shortly thereafter. She was a very nice lady. All of the usual VTE prophylaxis had been performed.

Nerdtonurse, frankly the person in your story deserved a PE or stroke. Play stupid games (like being that obese and intentionally sedentary before 40, smoking, discontinuing warfarin out of laziness, etc.), win stupid prizes. I prefer it when people reap what they sow vs. some clean living, nice person comes down with something horrible.

DroogieRN · Feb 8, 2012

Nerdtonurse, frankly the person in your story deserved a PE or stroke. Play stupid games (like being that obese and intentionally sedentary before 40, smoking, discontinuing warfarin out of laziness, etc.), win stupid prizes. I prefer it when people reap what they sow vs. some clean living, nice person comes down with something horrible.

Seriously? Wow.

Perpetual Student · Feb 8, 2012

If someone chooses to completely disregard every single health teaching and live a lifestyle that is WAAAAAAAAAAY higher risk than average, yes. If someone seeks care for their multiple comorbidities and then just decides "this treatment thing is too much work" and stops taking an anticoagulant that I guarantee they've been educated is to prevent them from having clots/stroking out, then darn skippy they're asking for what happens next. The described patient's problems all stemmed from pure laziness.

Her husband sounds like a total tool, too. Perhaps he should've encouraged his wife to be compliant with important therapies, lose weight, stop smoking, etc. instead of just seeking someone to blame when her decision making led to her demise.

If I drink too much and drive myself home, forgetting to put on my seat belt, I deserve to fly through the windshield. Decisions and actions often have consequences.

digitiminimi · Feb 8, 2012

Is it common to see a young pt with a PE or blood clots from birth control only and no other risk factors? I always wonder how often this happens - can't really find statistics.

boyfactory · Feb 8, 2012

I had one last fall as well. It was a 20 something as well. Came in to the ED with parents, who registered, the pt went to the restroom for like 10 minutes. When they came out, they sat in the chair and kind of collapsed there, alert but responsive. The triage nurse saw it, called us in back. We rolled out a stretcher and started working immediately. We worked for almost an hour and finally called it. It was so textbook though, purple from the nipples up. The autopsy did say, there was clot that had gotten caught in the LAD, causing the death.

This same patient had been c/o SOB for 2 weeks. Had an appt scheduled for the MD and cancelled it, if I recall.

RockingItInTheER · Feb 9, 2012

true he couldnt have been too healthylooking back I realized he was only in my bed one hour before we were codingbut I still thought when it was all over couldn't we have done betterI guess cause he was my youngest code

Altra, BSN, RN · Feb 9, 2012

Is it common to see a young pt with a PE or blood clots from birth control only and no other risk factors? I always wonder how often this happens - can't really find statistics.

http://www.emedicinehealth.com/understanding_birth_control_medications_contrace/article_em.htm

Thromboembolism

(blood clots):

Women who use estrogen-containing birth control pills are at a 3- to 6-fold increased risk of developing blood clots. Blood clots may lead to

deep vein thrombosis

, heart attack, or stroke. Additional causes of blood clots include advanced age,

obesity

,

family history

, recent surgery, and pregnancy. Low-dose (less than 50 mcg of ethinyl estradiol) oral contraceptives pose less risk than older, higher-dose formulations.

Cigarette smoking

increases the risk of blood clots in women using combination contraceptives, particularly for women older than 35 years and those who smoke more than 15 cigarettes per day.

Similar language is on the package insert of all oral contraceptives prescribed in the U.S.

Some journal articles:

http://www.ijgo.org/article/S0020-7292(10)00556-4/abstract

http://bloodjournal.hematologylibrary.org/content/111/3/1282.short

http://journals.lww.com/ccmjournal/Abstract/2010/02001/Thrombotic_risk_factors__Basic_pathophysiology.2.aspx