A 56-year-old obese female comes to the emergency department (ED) for evaluation of sudden-onset left-sided lower chest pain and shortness of breath. Her past medical history includes cholelithiasis, hypertension, hypothyroidism, and hyperlipidemia. Her medications are hydrochlorothiazide, amlodipine, aspirin, and levothyroxine. She has a 35-pack-year smoking history and continues to smoke one pack of cigarettes daily. Initial work-up in the ED reveals a large left-sided pulmonary embolism, left lower lobe pulmonary infarction, and right popliteal vein thrombosis. She is admitted to the hospital and started on subcutaneous enoxaparin and warfarin. On the third hospital day, she develops weakness and dizziness and produces 500 ml of coffee grounds emesis. Physical examination reveals a temperature of 36.7 C (98 F), heart rate of 110/min, blood pressure of 98/54 mmHg, and respiratory rate of 26/min. Her hemoglobin level is 9.8 g/dL (12.6 g/dL on admission) and platelet count is 320,000/mm³ (210,000/mm³ on admission). Upper gastrointestinal endoscopy shows multiple stomach ulcers and erosions. She is started on high-dose pantoprazole. Which of the following is the most appropriate next step in the management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient received appropriate initial management of her pulmonary embolism (PE) including anticoagulation with subcutaneous enoxaparin and warfarin. However, she has now had a complication of anticoagulation in the form of upper gastrointestinal bleeding from previously undiagnosed stomach ulcers. The large drop in her hemoglobin, plus the accompanying tachycardia and borderline blood pressure, tell us that this bleed was substantial. The patient should be resuscitated with fluids and her anticoagulation stopped. Placement of an inferior vena cava (IVC) filter would be appropriate at this time. Indications for IVC filter placement include: complications of anticoagulation, contraindications to anticoagulation, or failure of anticoagulation in the setting of a known DVT or PE. (Choice A) Continuing both the enoxaparin and warfarin would place the patient at risk for continued gastrointestinal hemorrhage and would not be appropriate. (Choice B) Continuing the enoxaparin alone would also place the patient at risk for future gastrointestinal hemorrhage. (Choice C) Continuing only the warfarin would leave the patient inadequately anticoagulated in the short term and would risk recurrent gastrointestinal hemorrhage once the patient's INR becomes therapeutic. (Choice E) Aspirin is not adequate anticoagulation for a patient with a pulmonary embolism. Educational objective: Anticoagulation with heparin or a low molecular weight heparin followed by oral warfarin is the treatment of choice for a patient with pulmonary embolism. An IVC filter is recommended in patients with complications of anticoagulation, contraindications to anticoagulation, or failure of anticoagulation.

A 56-Year-Old Obese Female Comes to the Emergency Department (ED)