Pulmonary embolism

Five days after a bilateral salpingo-oophorectomy and total abdominal hysterectomy, your 62-year-old patient complains of breathlessness and right-sided chest pain. You suspect she might have suffered a pulmonary embolism. Describe your initial plan of management.

If she has had a major pulmonary embolism, the patient may have circulatory collapse and require resuscitation. Your priority will be an assessment of her cardiovascular system. Provided the patient is stable, you can proceed with your investigations. These will include an ECG, arterial blood gas analysis, a chest X-ray and either a CT pulmonary angiogram (CTPA) or a ventilation-perfusion (V/Q) isotope scan performed The CTPA will allow accurate definition of the major pulmonary vasculature and can detect filling defects and obstruction. The scans are undertaken after rapid bolus administration of 100–140mLof non-ionic contrast. This technique can be used to detect 3–4-mm clots in the second-, third- and fourth-order branches of the pulmonary vasculature. The V/Q scan (looking for mismatch defects) is better in the definition of peripheral lung lesions.

Once the diagnosis of pulmonary embolism has been confirmed, the patient should be given intravenous heparin.

Clinical examination of a patient with suspected deep venous thrombosis (DVT) or pulmonary embolism is relatively inaccurate and should not be relied on to determine diagnosis or treatment.

Fever

Six days after an open appendicectomy and removal of a perforated appendix, your 45-year-old patient develops a fever. He has a temperature of 38.5.C and a tachycardia of 100 beats per minute. Describe your actions at the bedside.

The temperature is almost certainly the result of sepsis, and the timing of the fever in relation to the date of the procedure suggests that the infection probably originates at the site of the operation (rather than the chest).

First, make an overall assessment of the general state of health of the patient. Is he relatively well, or is he about to slip into septic shock? Establish the progress since the operation. Inquire if there is anything that may predispose the patient to infection; for example, he might be a diabetic. Look at the nursing observation chart and observe the pattern of the fever and pulse rate. This may give a clue as to the likely cause. A spiking fever over several days could be due to an intra-abdominal abscess.

Although a chest infection may not be the cause of the fever, the chest must be examined carefully. After that, the abdomen should be inspected and the wound examined. Cannula and drain sites should also be examined for evidence of infection. Occasionally, a DVT will be accompanied by a low-grade fever, and the legs should be examined.

The patient has only recently spiked the fever and prior to this had been making an uneventful recovery from his operation. He was otherwise in good health before developing appendicitis. The only abnormal finding is a 2-cm tender and red swelling in the middle of the wound, with a narrow margin of surrounding erythema. What would you do?

This problem may be solved relatively easily by an incision into the abscess. It is possible to do this at the bedside. Explain to the patient the problem and what you propose to do. Provided the incision is kept within the previous incision, it should be relatively pain-free. A small nick with a scalpel could be all that is required to relieve the problem. Otherwise, the patient could be provided with some analgesia and then the abscess drained more formally under local anaesthetic. This would enable the wound to be probed and opened somewhat more than might have been achieved with a scalpel blade alone.

There is no need for investigation or antibiotics; the problem is one of localised superficial infection.

Initial assessment of a patient with suspected sepsis must include an appreciation of the type of procedure undertaken and the risk of infection from that procedure. Also to be considered are the consequences, should infection in that particular patient occur, for example, reduced resistance to infection in an immunocompromised individual. The type of procedure and the pattern of fever will give important clues as to the site of sepsis and the causative organism. Investigations to be considered include those to:

• identify the site of infection

• diagnose the type of infection.