Safety of early orthopedic surgery in patients with intermediate/low- or low-risk pulmonary embolism

Perioperative Management of Incidental Pulmonary Embolisms on Trauma CT Scans: A Narrative Review

Unsuspected pulmonary embolism (PE) may be identified on an initial trauma computed tomography (CT) scan. The clinical importance of these incidental PEs remains to be elucidated. In patients who require surgery, careful management is needed. We sought to investigate the optimal perioperative management of such patients, including the use of pharmacological and mechanical thromboprophylaxis, possible thrombolytic therapy, and inferior vena cava (IVC) filters. A literature search was conducted, and all relevant articles were identified, investigated, and included. Medical guidelines were also consulted where appropriate. Pharmacological thromboprophylaxis is the mainstay of preoperative treatment, and low-molecular-weight heparins, fondaparinux, and unfractionated heparin may all be used. It has been suggested that prophylaxis should be administered as soon as possible after trauma. Such agents may be contraindicated in patients with significant bleeding, and mechanical prophylaxis and inferior vena cava filters may be favoured in these patients. Therapeutic anticoagulation and thrombolytic therapies may be considered but are associated with an increased risk of haemorrhage. Delaying surgery might help to minimise the risk of recurrent venous thromboembolism, and any interruption of prophylaxis must be strategically planned. Recommendations for postoperative care include a continuation of prophylaxis and therapeutic anticoagulation, with follow-up clinical evaluation within six months. Incidental PE is a common finding on trauma CT scans. Although the clinical significance is unknown, careful management of the balance between anticoagulation and bleeding is needed, especially in trauma patients and even more so in trauma patients requiring surgery.

Submassive Pulmonary Embolism Complicating Small Bowel Obstruction

The evaluation of patients with pulmonary embolism (PE) requires a comprehensive approach that assesses physical and laboratory exam findings, interprets varying imaging modalities, and selects appropriate treatment strategies. Comorbidities can complicate treatment and influence physicians to make difficult management decisions. In this case report, we present a patient with a small bowel obstruction complicated by submassive intermediate high-risk PE. Stratifying risk in PE patients is crucial to gauge when to use invasive interventions. There is limited clinical data to identify the optimal timing of surgery in patients with concurrent PE. We describe a challenging case where a patient requires multiple life-saving interventions; however, each treatment method carries a risk of bleeding or further complicating surgical candidacy. The patient in question first undergoes treatment of PE to improve hemodynamics and lower the clot burden prior to proceeding with resection of the small bowel. This report emphasizes the utility of the Pulmonary Embolism Response Team to facilitate care when surgical comorbidities require immediate attention as well.