Case Of Fatal Pulmonary Embolism Research Articles

Optimization of proper diagnosis of thromboses associated with high risk of embolism in patients with neoplasms

Aim. To optimize a proper diagnosis of thromboses associated with high risk of embolism and pulmonary embolism prevention in patients with neoplasms. Methods. Ultrasonography of veins of lower extremities, iliac veins and the distal part of inferior vena cava was performed in patients with and without neoplasms in a prospective study to detect thromboses associated with high risk of embolism and thrombophlebitis. Ultrasonography was performed once in control group subjects, and before and during specialized antineoplastic treatment (surgical, chemotherapy, radiotherapy) in patients of the main group, the results were compared. A detection of a new thrombus in previously intact venous segment of inferior vena cava system was assessed as a high risk for pulmonary embolism. Results. Thromboses associated with high risk of embolism and thrombophlebitis were found in 6 patients of control group, in 5 patients of the main group before and in 27 patients of the main group while at specialized antineoplastic treatment. Specific measures for pulmonary embolism prevention were taken immediately in all of the cases according to ultrasonography results after the detection of thromboses associated with high risk of embolism. No fatal cases of pulmonary embolism were registered both in main (before and while at treatment) and control groups. Conclusion. Ultrasonography of veins of lower extremities, iliac veins and the distal part of inferior vena cava in patients with neoplasms before the start of specialized antineoplastic treatment allows to optimize the choice of prevention measures for pulmonary embolism and thus significantly decreases mortality from pulmonary embolism.

Fatal Pulmonary Embolism following Achilles Tendon Repair: A Case Report and a Review of the Literature

Deep venous thrombosis (DVT) is a significant source of morbidity in orthopaedic surgery. It can progress to a pulmonary embolism, a significant source of mortality. Up to date, patients with Achilles tendon rupture routinely do not receive DVT chemical prophylaxis. We are presenting a case of fatal pulmonary embolism after a surgically treated Achilles tendon rupture in a forty-two-year-old male healthy patient. In the current body of the literature, the reported incidence of DVT after Achilles tendon rupture is highly variable ranging from less than 1% to 34%, and there is a disagreement in the international guidelines regarding the need of chemical DVT prophylaxis with this type of injury. Further research needs to be conducted to investigate the risks and benefits of chemical DVT prophylaxis following Achilles tendon rupture. For low-risk patients, the use of milder forms of prophylaxis such as aspirin should also be explored.

Fatal pulmonary embolism subsequent to the use of Esmarch bandage and tourniquet: A case report and review of literature

We report a case of fatal pulmonary embolism (PE) following exsanguinations of lower limb in orthopedic surgery. A 30-year-old man was posted for fixation of a tibial plateau fracture on the seventh day after injury. Subarchnoid block was performed. Esmarch bandage was used for exsanguination of the limb and tourniquet was inflated. Within three minutes after tourniquet inflation, the patient became unconscious hypotensive, and collapsed. Resuscitation was instituted and spontaneous circulation restored. Right ventricular strain pattern on transthoracic echocardiography, increased levels of D-dimer, and Doppler examination of the lowerlimb confirmed deep venous thrombosis of right femoral vessels and PE. In spite of thrombolytic therapy with streptokinase and heparin, the patient died on the ninth day after the event. Cases of PE secondary to the use of Esmarch bandage and tourniquet are reviewed here to identify the risk groups and management of PE.

Is Thromboprophylaxis After Knee Arthroscopy Warranted?

The management of venous thrombophlebitis and thromboembolic disease has challenged the medical community for decades. The diagnosis can be elusive because of absent or mild clinical symptoms, and the potential outcome can be catastrophic. Major venous thromboembolic events (VTEs) are uncommon after outpatient knee arthroscopy, although many orthopaedic surgeons are aware of cases of fatal pulmonary embolism (PE) after this “low risk” surgery. In their paper, Maletis et al. use a large administrative database from the Kaiser Permanente Health Maintenance Organization to analyze the incidence of symptomatic VTE after knee arthroscopy. The records of almost 22,000 patients were retrospectively reviewed to identify ICD-9-CM procedure codes associated with symptomatic deep venous thrombosis (DVT) or PE during a ninety-day postoperative period. The incidence of symptomatic DVT during this period …

Fatal pulmonary embolism after surgery for a clavicle fracture: A case report

Patients undergoing upper extremity surgery generally have a low risk of pulmonary embolism. We encountered a rare case of fatal pulmonary embolism after surgical treatment of a clavicle fracture. A 46-year-old man fell off the roof of his car and suffered fractures of the left clavicle, temporal bone and ribs, as well as cerebral and lung contusions. He was admitted to a local hospital, and was later transferred to our hospital for surgical treatment of the clavicle fracture at 6 days after injury. He had no dyspnea and was ambulant. On day 7 after the injury, open reduction and internal fixation of the clavicle fracture using a plate and screws were performed under general anesthesia. Although surgery was uneventful, the patient had bradycardia postoperatively that progressed to cardiopulmonary arrest, which required resuscitation and intubation. Spontaneous cardiac output was restored 10 minutes after cardiac arrest, but the GCS score was E1V1M2. Enhanced CT of the chest revealed a 15 mm defect in the right pulmonary artery, leading to a diagnosis of pulmonary embolism. Thrombolytic therapy was started immediately. However, the patient’s condition worsened and he died 20 days postoperatively. We suggest that use of mechanical and chemical thromboprophylaxis should be considered for clavicle surgery.

Long-term therapy with low-molecular-weight heparin in cancer patients with venous thromboembolism

Long-term therapy with low-molecular-weight heparin (LMWH) is the treatment of choice for cancer patients with venous thromboembolism (VTE). However, the ideal doses of LMWH have not been thoroughly studied. We used the RIETE Registry data to assess the influence of the daily LMWH dosage on outcome during the first three months after VTE. We used propensity score-matching to compare patients who received <150 vs. those receiving ≥150 UI/kg/day LMWH. Up to July 2010, 3,222 cancer patients with VTE received long-term therapy with fixed doses of LMWH. Of these, 1,472 (46%) received <150 IU/kg/day (mean, 112 ± 28), and 1,750 received ≥150 IU/kg/day (mean, 184 ± 32). Results of the propensity score matching involved 1269 matched pairs. During follow-up, the incidence of pulmonary embolism (PE) recurrences was similar (1.2% vs. 1.9%), but patients receiving <150 IU/kg/day LMWH had a lower incidence of fatal PE than those treated with ≥150 IU/kg/day (0.2% vs. 1.0%; p=0.004). Multivariate analysis confirmed that patients receiving <150 IU/kg/day LMWH had a lower risk for fatal PE (odds ratio [OR]: 0.2; 95% confidence interval [CI]: 0.06-0.8) and for major bleeding (OR: 0.6; 95% CI: 0.3-1.0) than those treated with ≥150 IU/kg/day. In real life, one in every two cancer patients with VTE received lower doses of LMWH than those used in randomised trials, with large variations from patient to patient. Unexpectedly, patients treated with <150 IU/kg/day LMWH had fewer fatal PE cases and fewer major bleeding events than those receiving ≥150 IU/kg/day LMWH. This finding, however, should be validated in prospective clinical trials.

Fatal pulmonary embolism following conservatively managed tendo achilles rupture—A case report

IntroductionTendo achilles (TA) ruptures are commonly encountered in orthopaedic practice. These can be managed operatively or conservatively depending on various factors like patient age, activity levels, co morbidities, patient expectations and surgeon preference. They are usually treated in plaster cast immobilisation if managed conservatively. Case reportWe present a case of fatal pulmonary embolism following conservatively managed Tendo achilles (TA) rupture in a young man treated as an orthopaedic outpatient. DiscussionThere are no current clear guidelines on venous thromboembolism (VTE) prophylaxis in conservatively managed outpatients with cast immobilisation. ConclusionOur case report highlights the importance of recognition of this aspect of patient management and reviews the current literature available on this debatable topic.

Fatal pulmonary thromboembolism. A retrospective autopsy study: Searching for genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus

The accuracy of antemortem diagnosis of pulmonary embolism is within the range of just 10-30%, so representing one of the most frequent missed diagnosis in sudden, unexpected death. We describe 43 fatal cases of pulmonary embolism as confirmed by post-mortem examination. The aim of our study was to verify the systematic search for the most common genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. As a whole, 41 patients (95.3%) had at least one risk factor. Pre-existing symptoms are described just before fatal embolism in 18 (41.9%) out 43 patients. In 18 out of 43 (41.9%) it was not possible to find the thrombotic site. In 24 out of the remaining 25 cases the involvement of the deep veins of one leg was shown; in 1 case the thrombus was localised in the inferior caval vein. 10 (41.7%) were iliac vein thromboses, 7 (29.1%) femoral, 2 (8.3%) popliteal, 3 (12.6%) posterior-tibial, 1 (4.1%) anterior-tibial and 1 (4.1%) peroneal vein thromboses. In our cohort of patients, 4 (10%) out of 40 cases carried the 20210A prothrombin gene variant in heterozygosis. One (2.5%) out of 40 carried the Factor V Leiden (G1691A) gene variant in heterozygosis. Patients carrying these gene variants in homozygosis or carrying both were not present in our case-series. We strongly underline the relevance of a complete methodological approach, integrating clinical data by means of autopsy findings and histological study. On the contrary, investigating common inherited thrombophilia is not warranted.

Deep Venous Thrombosis and Pulmonary Embolism are Uncommon in East Asian Patients after Total Hip Arthroplasty

In Western countries, deep vein thrombosis (DVT) and pulmonary embolism (PE), are relatively common after THA and many surgeons recommend routine pharmacologic thromboprophylaxis. There is some suggestion in the literature that the incidences of DVT and PE may be lower in East Asian patients. Therefore, it would be important to establish the incidences in a large number of East Asian patients who did not receive pharmacologic thromboprophylaxis. We therefore determined the incidence of DVT and PE and evaluated the associated risk factors in a series of East Asian patients who underwent primary THA without pharmacologic prophylaxis. We retrospectively evaluated all 861 patients who underwent 992 elective primary THAs from May 2003 to December 2009. We identified patients with symptomatic DVT, symptomatic PE, and fatal PE. For potential risk factors we considered age, gender, body mass index (BMI), administration of aspirin, type of anesthesia, operation time, approach, simultaneous bilateral THAs, and duration of immobilization between symptomatic and asymptomatic patients. We identified eight patients with symptomatic DVT, one of whom also had a symptomatic PE; there were no cases of fatal PE. The incidences of fatal PE, symptomatic PE, and symptomatic DVT were 0 %, 0.1 %, and 0.8 %, respectively. Longer duration of immobilization predicted symptomatic DVT or PE. East Asian patients have a low incidence of symptomatic DVT and PE and virtually no fatal PEs after primary THA. The incidences and risk factors should be taken into consideration when deciding whether to prophylactically treat these patients with pharmacologic agents. Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ethnic Differences in Out-of-Hospital Fatal Pulmonary Embolism

In-hospital pulmonary embolism (PE) has been extensively studied in large populations; however, out-of-hospital fatal PE studies are rare. Here, we systematically evaluated a large number of decedents who suffered fatal PE outside of hospitals and were subsequently investigated by the New York City Office of Chief Medical Examiner. A total of 578 consecutive out-of-hospital fatal PE cases were analyzed. All underwent autopsy, toxicology, microbiology, and genetic testing. Incidence rates and baseline characteristics were analyzed. Race-adjusted incidence rates of out-of-hospital fatal PE (per 100 000 people per year) were as follows: blacks, 3.73 (95% confidence interval, 3.31 to 4.11); whites, 1.15 (95% confidence interval, 0.96 to 1.33); and Hispanics, 0.93 (95% confidence interval, 0.72 to 1.10). Overall, obesity (body mass index ≥30 kg/m(2)) was 2.5- to 3-fold higher in fatal PE cases than in the New York City population as a whole. Carrier frequencies for prothrombin G20210A in fatal PE were 2- to 10-fold higher than reported frequencies in ethnically matched controls. Cumulative distribution curves showed that compared with whites, blacks and Hispanics died at significantly younger ages (P<0.001). Univariate and multiple linear regression analyses showed that in addition to nonwhite ethnicity, heterozygous carriers for factor V Leiden (P=0.001) and obesity (P=0.002) are significantly associated with younger age at death. There are unique epidemiological differences in out-of-hospital fatal PE between ethnic groups in New York City.

Successive Treatment With Cyclosporine and Infliximab in Steroid-Refractory Ulcerative Colitis

Rescue therapy with either cyclosporine (CYS) or infliximab (IFX) is an effective option in patients with intravenous steroid-refractory attacks of ulcerative colitis (UC). In patients who fail, colectomy is usually recommended, but a second-line rescue therapy with IFX or CYS is an alternative. The aims of this study were to investigate the efficacy and tolerance of IFX and CYS as a second-line rescue therapy in steroid-refractory UC or indeterminate colitis (IC) unsuccessfully treated with CYS or IFX. This was a retrospective survey of patients seen during the period 2000-2008 in the GETAID centers. Inclusion criteria included a delay of <1 month between CYS withdrawal (when used first) and IFX, or a delay of <2 months between IFX (when used first) and CYS, and a follow-up of at least 3 months after inclusion. Time-to-colectomy, clinical response, and occurrence of serious adverse events were analyzed. A total of 86 patients (median age 34 years; 49 males; 71 UC and 15 IC) were successively treated with CYS and IFX. The median (± s.e.) follow-up time was 22.6 (7.0) months. During the study period, 49 patients failed to respond to the second-line rescue therapy and underwent a colectomy. The probability of colectomy-free survival (± s.e.) was 61.3 ± 5.3% at 3 months and 41.3 ± 5.6 % at 12 months. A case of fatal pulmonary embolism occurred at 1 day after surgery in a 45-year-old man. Also, nine infectious complications were observed during the second-line rescue therapy. In patients with intravenous steroid-refractory UC and who fail to respond to CYS or IFX, a second-line rescue therapy may be effective in carefully selected patients, avoiding colectomy within 2 months in two-thirds of them. The risk/benefit ratio should still be considered individually.

A nationwide, retrospective analysis of symptoms, comorbidities, medical care and autopsy findings in cases of fatal pulmonary embolism in younger patients.

Our objective was to provide a comprehensive description of fatal pulmonary embolism (PE) in younger persons. Specifically, we recorded information on symptoms, comorbidity, medical contact, if this had been required, and subsequent autopsy findings. We reviewed all death certificates from persons aged 0-35 years who had died between 1 January 2000 and 31 December 2006, and retrospectively identified all cases of fatal PE. Additional information was retrieved from the National Patient Registry, autopsy reports, and clinical charts. Sixty-one cases of fatal PE were included; 38% of these were in males. The median age was 29 years. The predominant symptoms were dyspnea, syncope, leg pains, and chest pains. Sixty-three per cent of patients reportedly experienced symptoms for days, weeks, or months. More than half of the patients had sought medical care, and at the time of medical evaluation the majority of the patients were not hemodynamically compromised. In 21% cases, the correct diagnosis was reached before death; however, in only 5% of cases was this accomplished before clinical deterioration. Furthermore, clinical history and subsequent postmortem examinations showed that approximately half of younger persons dying from PE were otherwise healthy, and in no case was occult cancer diagnosed. Our data show that a substantial proportion of younger victims of fatal PE had experienced symptoms for an extended period of time. Furthermore, the correct diagnosis remained elusive in the majority of cases, even though approximately half of the subjects had sought medical evaluation for symptoms that, in retrospect, were most likely caused by a venothrombotic event.

Fatal Pulmonary Embolism Following Antipsychotic Treatment and Physical Restraint

We report on a case of fatal pulmonary embolism in a 68-year-old patient receiving antipsychotic treatment with haloperidol and olanzapine for acute exacerbation of her schizophrenia and having been physically restrained for 27.5 h. Pulmonary embolism was verified by autopsy. With reference to a review of the recent literature we briefly discuss current recommendations for prophylaxis of venous thromboembolism (VTE) in clinical psychiatry, which is a rare but highly relevant complication of antipsychotic treatment.

Clinical Efficacy of Mechanical Thromboprophylaxis Without Anticoagulant Drugs for Elective Hip Surgery in an Asian Population

To evaluate the clinical efficacy of mechanical thromboprophylaxis after elective hip surgery, we reviewed 3016 patients who underwent hip surgery at 5 centers. Primary total hip arthroplasty (THA), revision THA, and pelvic or femoral osteotomies were performed in 2648, 298, and 70 patients, respectively. Epidural anesthesia, intraoperative calf bandage, early mobilization, and intermittent pneumatic compression postoperatively with additional use of elastic stockings were the basic regimen for thromboprophylaxis. Postoperatively, no cases of fatal pulmonary embolism (PE) were encountered. One symptomatic PE and 4 symptomatic deep vein thrombosis cases were identified, all of which were successfully treated using heparin and warfarin. By 6 months, no deaths had occurred. We conclude that mechanical thromboprophylaxis without anticoagulant drugs is safe and effective for elective hip surgeries in our patient population.

Prevention of venous thromboembolism in medical patients and outpatients

The majority of fatal cases of pulmonary embolism in hospitalized patients occur in acutely ill, medically treated patients. Current guidelines, based on a large number of prospective, randomized, controlled trials evaluating the safety and efficacy of pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients, now recommend using VTE prophylaxis in this population. Unfortunately, prophylaxis rates in medical patients are unacceptably low, despite efforts to develop strategies for improving implementation of prophylaxis regimens. Studies indicate that a substantial proportion of patients with VTE present after hospital discharge, but no clinical trials evaluating VTE prophylaxis for medical outpatients have yet been published. In this Review, we examine the literature on VTE prophylaxis in hospitalized medical patients, and evaluate the available data for the outpatient setting.

Histological age determination of venous thrombosis: A neglected forensic task in fatal pulmonary thrombo-embolism

The histological age determination of venous thromboses in fatal pulmonary embolism cases is an important task of forensic medicine and requires thorough knowledge of the general and specific pathology of pulmonary thromboembolism (PTE). The aim of our investigation was to carry out a chronological evaluation of the deep venous thrombosis (DVT) phenomenon, to assess the chronological transformation of the thrombus and to determine the causal relationship with PTE as cause of death. The clinical data and the autopsy records of the 2843 autopsies performed over the period 1 November 1998 to 31 December 2007 were retrospectively evaluated, and 140 cases in which PTE was pointed out as cause of death were selected. The dissection of the deep veins of the legs has been performed systematically to search for the starting point of venous embolism. 4.5% of pulmonary embolisms originated in the in iliac veins, 20.7% in the femoral veins, and 74.8% in the deep crural veins. In the venous sites of thrombosis, the histological assessment has been performed in conjunction with the surrounding vascular wall of uncut blood vessel with at least three to six different transverse incisions. Histological assessment of the embolus samples was also performed in conjunction with the venous sites of thrombosis. In our selected 140 cases of PTE, the DVT was classified as phase 1 in 48 cases (34.29%), as phase 2 in 70 cases (50%), and 22 cases (15.71%) were evaluated as older than 2 months (phase 3). The observed transformation of the thrombus by organization is suitable for a forensically utilizable age determination. However, only three chronological stages can be distinguished with any degree of certainty using immunohistochemistry and CLSM.

Fatal Pulmonary Embolism in a Polytraumatized Patient Following Hip Arthroscopy

Prophylaxis of venous thromboembolic disease for patients undergoing orthopedic procedures remains a controversial topic. Deep venous thrombosis and pulmonary embolism are well studied in the total joint arthroplasty population, as are the various options for prevention and treatment. In the past few years, hip arthroscopy has enjoyed increasingly broader indications and applications, especially in patients who have suffered trauma to the hip. Current studies of hip arthroscopy, however, have not reported venous thromboembolic disease as a complication. No guidelines exist for venous thromboembolic disease prophylaxis associated with hip arthroscopy, perhaps because the need for such guidelines has not materialized. This article describes a case of fatal pulmonary embolism associated with hip arthroscopy after traumatic injury. A literature review reveals that this is the first report of this complication and that no guidelines exist regarding prophylaxis of venous thromboembolic disease in hip arthroscopy. Surgeons performing this technique should make treatment decisions on an individualized basis, considering patient- and injury-specific factors.

The incidence of symptomatic venous thromboembolic events in orthopaedic surgery when using routine thromboprophylaxis

Few studies have shown the effect of thromboprophylactic regimen with low molecular weight heparin (LMWH) on the incidence of clinical venous thromboembolism (VTE) in common practice. The aim was to study the three-year incidence of clinically overt VTE events at a university based orthopaedic department with some 3300 operations performed and 15 000 patients treated annually. Since all Swedish citizens have an individual identification number it was possible tp follow up all patients operated during a 3 year period (2000-2002) for a period of four months. The incidence of VTE in the classical high-risk groups of hip fracture surgery, total hip arthroplasty (THA) and total knee arthroplasty (TKA) was low - about 0.6 %, while the Pulmonary embolism (PE) incidence in the hip fracture group was 0.27%, with two cases of fatal PE occurring 72 and 109 days after surgery. Patients with ankle fractures had more VTE. The majority of clinical VTE occurred after discharge from hospital. When using routine thrombopropylaxis with LMWH in orthopaedic surgery the rate of symptomatic VTE is low.

Treating Acute Pulmonary Embolism: Outpatient or Inpatient or Somewhere in between

It is estimated that about 237,000 non-fatal and 294,000 fatal cases of pulmonary embolism occur in the United States each year [1]. Acute pulmonary embolism generally can be classified as either massive pulmonary embolism or non-massive stable pulmonary embolism [2]. Patients with massive acute pulmonary embolism have a poor prognosis and the first few hours is the critical period when the majority of deaths occur. It is during this narrow window when prompt diagnosis and rigorous treatment strategies can save lives [3].

Comparison of the clinical usefulness of two quantitative D-Dimer tests in patients with a low clinical probability of Pulmonary Embolism

Background Quantitative D-Dimer tests are established methods in the non-invasive diagnostic management to rule out venous thromboembolism (VTE). The diagnostic performance and the clinical efficiency different D-Dimer assays in the exclusion of pulmonary embolism (PE) have not yet been compared in a clinical outcome study. Objective Evaluation of the efficiency and safety of excluding the diagnosis of PE with two different quantitative D-Dimer assays in consecutive patients with clinically suspected PE. Patients and Methods We studied the VTE-failure rate of 2206 consecutive patients with an unlikely clinical probability in whom VIDAS or Tinaquant D-Dimer tests were performed. Results The prevalence of PE in 1238 patients whose D-Dimer level was analyzed with Tinaquant assay was 11%. The VIDAS assay group consisted of 968 patients with a PE prevalence of 13%. The VIDAS assay had a sensitivity of 99.2% (95%CI; 96- > 99.9%), the Tinaquant assay of 97.3% (95%CI; 93 -99%). The negative predictive value (NPV) in the Tinaquant assay group was 99.4% (95%CI 98-99.8%) in comparison to 99.7% (95%CI 99-> 99.9%) in the VIDAS assay group. During 3 month of follow-up, there were no fatal cases of PE among patients with normal D-Dimer and unlikely clinical probability in both D-Dimer assay groups. In addition, the test efficiency of Tinaquant assay was significantly higher in comparison to VIDAS assay (52% vs 42%, p < 0.001). Conclusion Both Tinaquant and VIDAS D-Dimer tests perform equally well in combination with an unlikely clinical probability in excluding PE. The Tinaquant test was shown to be more efficient.