From the Guidelines
The likely cause of pulmonary embolism in this elderly patient with COPD and severe asthma is immobilization, as it significantly increases the risk of deep vein thrombosis (DVT) due to venous stasis, especially in the context of advanced age and underlying inflammatory conditions. According to the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1, immobilization is a major risk factor for DVT, and the TESS score highlights the importance of age, lower extremities fracture, and ventilation in assessing the risk of VTE. The patient's age (≥ 65 years) and lower extremities fracture are significant predictors of VTE, with 2 TESS points each.
The combination of advanced age, prolonged bed rest after the fracture, and the inflammatory state associated with trauma significantly increases thrombosis risk. Cortisone treatment may have further contributed by promoting hypercoagulability. Additionally, the patient's underlying COPD and asthma create a baseline inflammatory state that predisposes to clot formation. The aggressive physiotherapy might have dislodged an existing thrombus from the leg veins, causing it to travel to the pulmonary circulation.
Key factors that contribute to the risk of pulmonary embolism in this patient include:
- Immobilization due to the femur neck fracture
- Advanced age (≥ 65 years)
- Underlying inflammatory conditions (COPD and asthma)
- Cortisone treatment
- Lower extremities fracture
For such patients, prophylactic anticoagulation should be initiated promptly after fracture diagnosis and continued throughout the immobilization period. Early mobilization when medically appropriate, compression stockings, and adequate hydration are also essential preventive measures. The combination of venous stasis from immobility, hypercoagulability from inflammation and medications, and possible endothelial injury creates the classic Virchow's triad conditions that predispose to thromboembolism, as highlighted by the study 1.
From the Research
Possible Causes of Pulmonary Embolism
- Immobilization is a well-known risk factor for developing pulmonary embolism, as it can lead to deep vein thrombosis (DVT) which can then break loose and travel to the lungs, causing a pulmonary embolism 2, 3, 4.
- The patient's recent fracture of the femur neck and subsequent immobilization may have increased the risk of developing DVT and subsequently pulmonary embolism 4.
- Aggressive physiotherapy may not be a direct cause of pulmonary embolism, but the underlying condition that required physiotherapy, such as immobilization, may have contributed to the development of pulmonary embolism 2.
- Cortisone treatment is not typically associated with an increased risk of pulmonary embolism, but it may be a contributing factor in certain cases, especially if it increases the patient's risk of developing DVT 3.
- NSAIDs are not mentioned in the provided evidence as a cause of pulmonary embolism in this patient.
Risk Factors for Pulmonary Embolism
- Immobilization is a significant risk factor for pulmonary embolism, as seen in the case of cast immobilization of the lower extremity 4.
- Trauma, such as a fracture, can also increase the risk of developing pulmonary embolism 5.
- The patient's underlying conditions, such as COPD and severe asthma, may have increased the risk of developing pulmonary embolism, but the exact mechanism is not clear from the provided evidence 2, 6.