A patient who regularly competes in Iron Man Triathlons came into the clinic tonight with complaints of pain with taking a deep breath. She had coughed up some blood once today and complained that it hurts when she takes a big breath in. She is an athlete and remembered running in a race about three weeks ago and developed pain in the right calf and behind the right knee. That pain has been improving over the last few weeks. As you can probably guess by the title of this blog entry, she had a blood clot in her lungs. Actually she had large blood clots called pulmonary emboli in both lungs. She required transport emergently to the hospital for treatment.
Definition: A pulmonary embolism (PE) is a blockage of one of the blood vessels to the lungs. These are usually caused by a blood clot that travels from somewhere else in the body, most commonly from the legs. Other causes of blockages to the blood vessels in the lungs are air bubbles, or from tiny pieces of fat.
A pulmonary embolism is a serious condition that is a medical emergency. A blocked artery or vein in the lung can make it hard to breath and can lead to damage to the lungs and can even cause death.
Most of the time the blood clots start in the legs, or in the pelvic area and then move along the veins and travel to the lungs.
Symptoms: People who have blood clots in the lungs might complain of:
1) Sharp, stabbing pain when they take a breath in
2) Coughing up blood
3) Rapid heart rate
4) Trouble breathing or feeling short of breath
If you have any of these symptoms, it is important to call 9-1-1 and be evaluated in the hospital. Do not try to drive yourself to the urgent care or to the hospital yourself.
Risk Factors: There are some factors that can increase the chance of having a blood clot in your lungs including:
1) Having a family history of blood clots or blood clotting disorders
2) Having recent surgery – especially on the knees, lower legs or pelvis
4) Taking birth control pills or estrogen replacement
5) Having a previous history of DVT (Deep Venous Thrombosis) or PE
6) Having a history of heart failure
7) Patients with cancer
8) History of kidney problems such as nephrotic syndrome
9) Having a recent trauma or injury with a large clot (hematoma) – more likely to cause DVT if it’s in the legs
Diagnosis: To diagnose a pulmonary embolism, special tests such as a special x-ray called a CT scan (Cat-Scan) with contrast. During this test, the patient has special a detailed x-ray of the lungs while contrast (a solution of medication that can be seen under x-ray) is put into a vein (usually in the arm) and circulates through the lungs and rest of the body. The CT scan is used to see the blood vessels and determine if a blood clot is present. There are other tests to determine if a pulmonary embolism is present as well such as a ventilation/perfusion lung scan, but we usually use CT scan instead because it is easier and less time consuming. If we suspect that there might be a blood clot in a patient’s leg, we can perform a vascular ultrasound to look for blood clots in the vessels of the legs.
Treatment: We start treatment of a pulmonary embolism without delay to prevent a new blood clot from forming and to reduce the chance of enlargement of the existing clot. Usually your own body’s enzymes dissolve the clot. We treat patients by anticoagulation. That means that we give medications to reduce the body’s abilities to form new blood clots – this is also sometimes called using “blood thinners.” It isn’t actually thinning the blood however. For patients who are at high risk for forming new blood clots, we sometimes put small screens or “filters” in a major blood vessel such as the inferior vena cava to prevent a new blood clot from reaching the lungs.
Most of the time we use a combination of oral anticoagulation medications such as Coumdin and also use an injectable medication such as heparin. Patients who have pulmonary embolisms often stay in the hospital for a few days and receive intravenous heparin to prevent more blood clots from forming. It takes a few days for the medication that is taken orally to become effective, so during this time the patient is giving the heparin either through an IV or the heparin is injected under the patients skin.
Patients who have had a PE usually take the Coumadin (also called Warfarin) for a minimum of three months. Some doctors recommend that patients with a PE take Coumadin or something similar for the rest of their lives. Other medications to prevent blood clots might be used if the patient is pregnant or cannot tolerate Coumadin.
Prevention: Patients who are in the hospital and confined to the bed for extended periods of time are usually started on a prophylactic dose of heparin each day or special compression devices on their legs to prevent blood clots. People who are on long air plane flights, car, bus or train rides should get up regularly and stretch their legs to help prevent the development of the blood clot in their legs (DVT). Patients who have had recent surgery often use heparin injections even at home for a few days to help prevent the development of a blood clot in their leg.
If you or someone you know if having symptoms of a pulmonary embolism (PE), they should dial 9-1-1 and go to the hospital immediately. They should not attempt to drive to the hospital or urgent care.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO