Model Answer
0 min readIntroduction
Prolonged immobilization, as seen in patients recovering from hip fractures, significantly increases the risk of venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). Breathlessness in this context is a concerning symptom that demands prompt investigation and management. PE, a potentially life-threatening condition, occurs when a thrombus dislodges from a deep vein (typically in the legs) and travels to the pulmonary arteries, obstructing blood flow. This answer will outline the potential causes of breathlessness in an elderly bed-ridden patient post-hip fracture and detail the management protocol for acute pulmonary embolism.
(i) Possible Causes of Breathlessness
In an elderly woman bed-ridden for four weeks post-hip fracture, several factors can contribute to breathlessness. These can be broadly categorized as pulmonary, cardiac, and other causes:
- Pulmonary Embolism (PE): This is the most concerning and likely cause given the prolonged immobilization. Hip fracture and subsequent bed rest are strong risk factors for DVT and subsequent PE.
- Pneumonia: Prolonged bed rest increases the risk of aspiration pneumonia and hospital-acquired pneumonia.
- Atelectasis: Reduced lung expansion due to prolonged bed rest and shallow breathing can lead to atelectasis (lung collapse).
- Chronic Obstructive Pulmonary Disease (COPD) exacerbation: If the patient has pre-existing COPD, the stress of the fracture and immobility could trigger an exacerbation.
- Heart Failure: Underlying cardiac conditions, potentially exacerbated by the stress of the fracture and fluid shifts, can lead to heart failure and breathlessness.
- Pericardial Effusion/Tamponade: Though less common, these can occur post-trauma or due to underlying cardiac disease.
- Anemia: Chronic illness and potential blood loss during surgery can contribute to anemia, causing breathlessness on exertion.
- Musculoskeletal causes: Pain from the fracture or associated muscle weakness can limit respiratory effort.
(ii) Management of Acute Pulmonary Embolism
The management of acute PE requires a rapid and systematic approach. The goals are to stabilize the patient, prevent further clot propagation, and minimize the risk of complications.
A. Initial Assessment & Stabilization
- ABCDE approach: Airway, Breathing, Circulation, Disability, Exposure. Ensure adequate oxygenation and ventilation.
- Vital Signs Monitoring: Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation.
- History & Physical Examination: Rapidly assess for risk factors for PE, symptoms (sudden onset breathlessness, chest pain, cough, hemoptysis), and signs (tachycardia, tachypnea, hypoxia).
B. Diagnostic Evaluation
- Electrocardiogram (ECG): May show sinus tachycardia, right bundle branch block, or S1Q3T3 pattern (though not specific).
- Chest X-ray: Often normal, but may show Westermark's sign (oligemia) or Hampton's hump (wedge-shaped pleural infarction).
- D-dimer: A highly sensitive but non-specific test. Elevated levels suggest the presence of a thrombus, but can be elevated in other conditions.
- CT Pulmonary Angiography (CTPA): The gold standard for diagnosing PE. Provides visualization of pulmonary arteries to identify clots.
- Ventilation/Perfusion (V/Q) Scan: An alternative to CTPA, particularly in patients with contraindications to CT contrast.
- Echocardiogram: Can assess right ventricular function and detect signs of pulmonary hypertension.
C. Pharmacological Management
Anticoagulation is the cornerstone of PE treatment.
- Unfractionated Heparin (UFH): Used for initial stabilization, especially in hemodynamically unstable patients. Requires monitoring of aPTT.
- Low Molecular Weight Heparin (LMWH): Preferred for most patients. Offers predictable anticoagulation and does not require routine aPTT monitoring.
- Direct Oral Anticoagulants (DOACs): (e.g., rivaroxaban, apixaban, edoxaban, dabigatran) Increasingly used as first-line therapy. Offer convenience and predictable pharmacokinetics.
- Thrombolysis: Reserved for patients with massive PE causing hemodynamic instability (hypotension, shock). Involves administering a thrombolytic agent (e.g., alteplase) to dissolve the clot. High risk of bleeding.
- Surgical Embolectomy: Rarely used, reserved for patients with massive PE who are contraindicated for thrombolysis or have failed thrombolytic therapy.
D. Supportive Care
- Oxygen Therapy: To maintain adequate oxygen saturation.
- Pain Management: Address chest pain with appropriate analgesics.
- Fluid Management: Careful fluid resuscitation to maintain hemodynamic stability.
- VTE Prophylaxis: Initiate VTE prophylaxis (e.g., LMWH, mechanical prophylaxis) once the patient is stable to prevent recurrent events.
Conclusion
Breathlessness in an elderly, bed-ridden patient post-hip fracture warrants a high index of suspicion for PE. Prompt diagnosis utilizing CTPA and appropriate anticoagulation are crucial for improving outcomes. A multidisciplinary approach involving physicians, nurses, and rehabilitation specialists is essential for optimal patient care and prevention of future thromboembolic events. Long-term anticoagulation duration should be individualized based on risk factors and bleeding risk.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.