Atypical Clinical Presentations of Pulmonary Thromboembolism to the Emergency Department: High Index of Suspicion and Application of Diagnostic Approach

ABSTRACT

Aim and background: Acute pulmonary thromboembolism is the most serious clinical presentation of venous thrombo-embolism with fatal pulmonary thromboembolism (PTE) being a common cause of sudden death. In yesteryears of practicing clinical medicine, PTE was the most common cause of unexplained sudden deaths in hospitalized patients. However, our understanding of the disease has improved with time and the growth of clinical scores, laboratory evidence, and radiographic scans. In few of the patients, the diagnosis is still missed and these are the nightmarish cases for the emergency physician. Especially after the second wave of the COVID pandemic, many patients presented to the emergency department (ED) even without any risk factors for pulmonary thromboembolism. Diagnosing patients without risk factors for PTE is quite challenging and suspicion of PTE should be kept in the differential diagnosis if patients are presenting with uncommon clinical history and examination. Objective: To decrease the incidence of missed diagnosis of PTE in ED. Materials and methods: The study was conducted using ED records of patients who had a confirmed diagnosis of PTE on CT pulmonary angiography (CTPA) between March and September 2021. COVID-19 infection was ruled out at the time of presentation to ED using a rapid antigen test and subsequently with RT PCR within the next 24 hours. The presenting complaints, past history of COVID-19 infection and COVID vaccination, WELLS score, ECG, CXR, ABG, D dimers, bedside echocardiography, and results of CTPA were collected and tabulated. The symptoms were divided into 2 groups-typical and atypical. Group I with typical symptoms studied patients who presented with acute onset of dyspnea, chest pain, and cough without expectoration. Group II with atypical symptoms included patients who presented with hemoptysis, wheeze, cerebrovascular accident, syncope, arrhythmias, and acute onset of delirium. The null hypothesis was that atypical symptoms of PTE make the diagnosis difficult (late) and have a poorer prognosis. Results: The comparative analysis with descriptive statistics will be presented at the conference. In Group II patients, three parameters were clinically significant enough to early diagnosis of PTE. These were sinus tachycardia on ECG, raised D dimers, and a low TAPSE on echocardiography. TAPSE or tricuspid annular plane systolic excursion with a cutoff <1.7 cm was found to be highly specific in our study. Conclusion: Acute pulmonary embolism can be a complex interplay between several different symptoms and between different organs that can lead to a potentially life-threatening cardiovascular condition that may be difficult to diagnose. The differential diagnosis of PTE should be kept in mind if a patient presents with rare clinical findings. Detailed physical examination, Wells-scoring, D dimers, and point of care ultrasonography (POCUS) examination are very crucial in diagnosing the patient. Working in this approach will decrease the incidence of missed diagnoses.