From the Guidelines
The likely cause of pulmonary embolism in this elderly patient with COPD and severe asthma is immobilization, as it is a major risk factor for deep vein thrombosis (DVT) following the femur neck fracture, according to the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1. The combination of advanced age, underlying respiratory conditions, recent trauma (fractured femur neck), and post-injury immobilization significantly increases thrombosis risk.
- Key factors contributing to this risk include:
- Advanced age (≥ 65 years) with a TESS score of 2, indicating a higher risk of VTE 1
- Lower extremities fracture, which adds 2 points to the TESS score, further increasing the risk of VTE 1
- Immobility, which is a well-established risk factor for DVT and subsequent pulmonary embolism
- Underlying respiratory conditions, such as COPD and severe asthma, which create a pro-inflammatory state that predisposes to clot formation The aggressive physiotherapy may have dislodged an existing clot, while cortisone treatment potentially enhanced blood coagulability.
- Preventive measures should include:
- Early anticoagulation therapy, such as low molecular weight heparin (LMWH), which has been shown to be effective in reducing the risk of DVT (RR 0.48) 1
- Graduated compression stockings
- Careful mobilization protocols to minimize immobility and reduce the risk of blood stasis in the deep veins of the legs Early recognition of DVT symptoms (leg swelling, pain, warmth) is essential, as is monitoring for pulmonary embolism signs (sudden shortness of breath, chest pain, rapid heart rate) during rehabilitation of similar patients. According to the Cochrane systematic review by Barrera et al., pharmacological prophylaxis, such as LMWH, is more effective than mechanical prophylaxis in reducing the risk of DVT, although it may increase the risk of bleeding (RR 2.04) 1.
From the Research
Possible Causes of Pulmonary Embolism
The likely cause of pulmonary embolism in an elderly patient with Chronic Obstructive Pulmonary Disease (COPD) and severe asthma, who developed a pulmonary embolism after aggressive physiotherapy and cortisone treatment for a fractured femur neck, can be attributed to several factors. The key considerations include:
- Immobilization: This is a significant 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.
- Surgery and Trauma: Patients who have undergone surgery or experienced trauma, such as a fracture, are at increased risk of developing pulmonary embolism 2, 4.
- Underlying Medical Conditions: Conditions like COPD and severe asthma can increase the risk of pulmonary embolism, especially when combined with other risk factors like immobilization or surgery.
Comparison of Options
Comparing the given options:
- A. Immobilization: This is a well-established risk factor for pulmonary embolism, especially in patients who have undergone surgery or experienced trauma.
- B. NSAIDs: While NSAIDs can have various side effects, they are not directly linked to an increased risk of pulmonary embolism in the provided studies.
Relevant Studies
Studies have shown that immobilization, surgery, and trauma are significant risk factors for developing pulmonary embolism 2, 4, 3. Additionally, the use of physical restraint or immobilization can also increase the risk of DVT and PE, even in the absence of pre-existing risk factors 5. The case of a patient developing pulmonary embolism after clomiphene therapy highlights that various factors can contribute to the risk of PE 6. However, in the context of the given scenario, immobilization due to the fracture and subsequent treatment appears to be the most directly related factor.