On day 3 of admission, she becomes acutely hypoxemic. Vitals are notable for BP 100/60, HR 120, SpO2 94% on 5L NC, T 36.9C. You obtain a chest X-ray, which just shows mild bibasilar atelectasis. Not satisfied, you obtain a CTA chest once she's stabilized. With this, acute right-sided segmental pulmonary emboli are discovered.
Well this is a suboptimal development. Diagnostically, there are a few additional things we need to do. For risk stratification, we should send off a BNP and hsTrop. We also need to obtain a TTE, as this will help identify whether there's any right heart strain and whether there are any other signs of hemodynamic problems. (The CTA chest may comment on interventricular septal flattening, but this is typically overcalled relative to TTE.) Is there utility in obtaining a DVU scan to look for DVT? Some. If there's a lower extremity DVT, you could consider placing an IVC filter to theoretically reduce the risk of additional clots migrating to the pulmonary vasculature. However, this would only be a short-term bridge to when she can actually get anticoagulated.
From a therapeutic standpoint, we know this patient will need therapeutic anticoagulation. She just had an acute-on-chronic SDH that got evacuated, so we're not thrilled about starting this now. If the patient is clinically stable, this can be reasonably delayed. However, we need to recognize that she may become more clinically unstable at some point, which would tip the risk/benefit profile in favor of anticoagulation.
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