Review Question - QID 220318

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Pulmonary Embolism Etiology Pathophysiology QID: 220318 (M2.OMB.4877)

QID 220318 (Type "220318" in App Search)

A 32-year-old woman presents to the emergency department with acute appendicitis and undergoes urgent laparoscopic appendectomy. After surgery, she is admitted to the hospital and is unable to get out of bed due to pain and fatigue. Her medical history is significant for opioid use disorder and factor V Leiden. She does not take any medications, drinks socially, and smokes 1 pack per day. Three days after the surgery, she experiences several episodes of shortness of breath as well as hemoptysis. She also develops chest pain and palpitations. Her temperature is 98.7°F (37°C), blood pressure is 106/64 mmHg, pulse is 127/min, and respirations are 16/min. Physical exam is significant for a loud P2 sound on cardiac exam. Which of the changes seen in Figure A would most likely be seen in this patient's right ventricular (RV) size, wall tension, and perfusion?

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This patient with dyspnea, hemoptysis, chest pain, palpitations, tachycardia, and hypotension most likely has a pulmonary embolism in the setting of immobility after appendectomy. The most likely set of changes would be increased right ventricular size, increased right ventricular wall tension, and decreased right ventricular perfusion.

A massive pulmonary embolism can result in cardiovascular instability caused by a mechanical obstruction of the pulmonary vasculature that exceeds 50% of the cross-sectional area. These massive clots can occur in patients who are immobilized and present with tachycardia, hypotension, hemoptysis, and chest pain. Pathophysiologic changes associated with this large scale occlusion of the pulmonary vasculature include dramatically increased resistance to the function of the right ventricle. This increased resistance results in increased wall tension as well as right ventricular dilation. The increased wall tension results in decreased right ventricular perfusion. Treatment of a massive pulmonary embolism associated with cardiovascular instability is with a blood thinner (often a heparin drip) and emergent embolectomy.

Singh and Lewis review the evidence regarding the diagnosis and treatment of a pulmonary embolism. They discuss how a massive pulmonary embolism results in right ventricular dysfunction. They recommend evaluating for this phenomenon to prevent progression to right heart failure.

Figure A is a table with changes in right ventricular size, wall tension, and perfusion.

Incorrect Answers:
Answer 1: Decreased right ventricular size, decreased right ventricular wall tension, and decreased right ventricular perfusion would be seen in patients who have hypovolemia. This condition can be caused by bleeding or dehydration and would present with hypotension, thirst, and dry mucous membranes. Treatment is with volume repletion.

Answer 2: Decreased right ventricular size, decreased right ventricular wall tension, and normal right ventricular perfusion would be seen in patients who have the early stages of hypovolemia that do not yet compromise perfusion. This would be seen in patients with class 2 or 3 hemorrhage. Treatment is with control of volume loss and volume repletion.

Answer 4: Increased right ventricular size, increased right ventricular wall tension, and increased right ventricular perfusion would be seen in patients who have hypervolemia with increased sympathetic tone. This might be true in an athlete who is well-trained.

Answer 5: Normal right ventricular size, normal right ventricular wall tension, and decreased right ventricular perfusion would be seen in patients who have coronary artery disease. While this disease could also present with chest pain and dyspnea, it would not typically present in a young patient without other risk factors.

Bullet Summary:
A large pulmonary embolism would present with increased right ventricular size, increased right ventricular wall tension, and decreased right ventricular perfusion.