CHEST Guidelines-A-93-Year-Old-Man-With-Submassive-Pulmonary-Emboli

A-93-Year-Old-Man-With-Submassive-Pulmonary-Emboli

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This medical case study details a 93-year-old man with a history of hypertension and stage 3 chronic kidney disease, who presented to the emergency department with sudden onset shortness of breath and lightheadedness. He was diagnosed with submassive pulmonary embolism, indicated by CT angiogram findings of filling defects in the pulmonary arteries and signs of right ventricular dilation. Despite initial treatment with intravenous heparin, further evaluation including point-of-care ultrasound (POCUS) revealed a gluteal hematoma, likely sustained from a recent fall. This discovery posed a contraindication for proceeding with catheter-directed thrombolysis.<br /><br />The POCUS examination, initially performed to assess cardiac issues, incidentally identified cobblestoning and a fluid collection in the left gluteal region, suggestive of an intramuscular hematoma. This finding led to further imaging with a CT scan, which confirmed the hematoma. Given this complication, thrombolytic therapy was deemed too risky due to potential exacerbation of the hematoma, altering the management approach.<br /><br />The case underlines the importance of POCUS in identifying soft tissue conditions that can critically impact the treatment plan for patients in the ICU. Specifically, in this context, POCUS helped prevent a potentially life-threatening bleed by highlighting an otherwise hidden complication. The study highlights how bedside ultrasound imaging can rapidly evaluate skin and soft tissues, detect hematomas or abscesses, and influence clinical decisions. This case advocates for training intensivists in POCUS for expedited diagnosis and management in critically ill patients, emphasizing the technology's role in complementing physical examinations before initiating risky therapies such as thrombolytics.

Keywords

pulmonary embolism

chronic kidney disease

POCUS

gluteal hematoma

intravenous heparin

thrombolytic therapy

point-of-care ultrasound

right ventricular dilation

bedside ultrasound

intensivist training