The differential diagnosis of chest pain can include many conditions including angina, myocardial infarction, costochondritis, and pulmonary embolism. In this article we are going to be looking at the field diagnosis and treatment of a pulmonary embolism.

Background

A Pulmonary Embolus occurs when a clot gets stuck in an artery in the pulmonary vasculature. Clots can be caused from blood, fat, bone marrow, tumor fragments, amniotic fluid, or air bubbles. These clots can affect preload to the left ventricle and/or oxygenation of the blood.

Incidence

More than 600,000 cases reported each year. 60,000 deaths within the first 4 hours. Leading cause of death in hospitals. Often times they are missed on initial presentation and found only on autopsy.

Signs and Symptoms

• Sudden death

• Pleuritic chest pain/chest wall tenderness (from distension of the pulmonary arteries)

• Hypoxia (lack of oxygenated blood returning to the heart)

• Hypotension (due to poor venous return to left ventricle)

• Tachycardia (to compensate for the decreased preload and to maintain cardiac output)

• Tachypnea (to compensate for hypoxia)

• Clear lung sounds

• Cyanosis around the nose and mouth (due to hypoxia)

• Dysrhythmias (PVC’s and Atrial Fibrillation)

• Leg swelling and tenderness (indicative of DVT)

• Friction rub

• Syncope (decreased cardiac output)

Field Diagnosis

• History

- Recent surgery or childbirth

- Immobility (bedridden patients, previous history of long travel)

- Certain medications (e.g. birth control)

- Hereditary coagulation disorders

- Smoking

• 3 Lead EKG: Sinus Tachycardia

• 12 Lead EKG: “S1Q3T3” Large S wave in Lead 1, Q wave in lead 3, inverted T wave in lead 3. Other EKG findings include: ST Depression may noted in lead II. Right atrial enlargement may also be noted in Lead II and V2. T wave inversion in V1 through 4. There may also be a right bundle branch block.

• End Tidal CO₂: hyperventilation with normal or high EtCO₂ levels. Patients who are suffering from anxiety will demonstrate hyperventilation with low EtCO₂ levels.

Treatment

• High flow oxygen

• Ensure adequate tidal volume and provide ventilations if needed

• Cardiac monitoring

• Obtain IV access

• Alert receiving facility

Here is an example of the S1Q3T3