Case-Based Modules > Case 27 > Stage 3

The patient's BNP is 100, and her hsTrop is 45. A TTE is obtained and demonstrates no evidence of right-sided pressure overload. You breathe a sigh of relief. You obtain BLE DVU scans, which do not reveal any DVT. You opt to defer therapeutic anticoagulation for now...

The very next day, the patient becomes more hypoxemic, and now endorses chest pain. She's satting 85% on 10L NC. Her hsTrop is rising to 120. Chest X-ray demonstrates a wedge-shaped area of opacification in the right upper lobe, concerning for a pulmonary infarct.

What other management steps do you take now?

Starting with her hypoxemia, clearly the nasal cannula is inadequate. This is all likely due to worsening of her pulmonary emboli, now with a pulmonary infarct. Intubation would be incredibly dangerous for her and would be at high risk of causing a cardiac arrest. (The positive pressure would be harmful to the RV here, and any drop in perfusion would also further exacerbate the cardiac compromise.) We can utilize high-flow nasal cannula, which should improve her oxygenation and work of breathing.

With her SDH and recent surgery, systemic or catheter-directed lysis are still contraindicated. However, we can-- and should-- therapeutically anticoagulate her. This is clearly a high-risk situation and the risk of further deferring this step would be too harmful. One way to approach this is to get a repeat non-contrast head CT to ensure stability, then start a heparin drip with no bolus ever. Once she's therapeutic per her anti-Xa level, then we would repeat another head CT to ensure nothing has gotten worse.


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