A Clinical Risk Case Study - The Importance of Undertaking Dispassionate Assessments and Highlighting Early Indicators of a Pulmonary Embolism

A Clinical Risk Case Study - The Importance of Undertaking Dispassionate Assessments and Highlighting Early Indicators of a Pulmonary Embolism

Setting the scene

The patient, in this case, had a history of syncope, breathlessness and diarrhoea. They were admitted to hospital after a collapse with loss of output and unexplained hypoxia.

On arrival to hospital the patient underwent an ECG which showed abnormalities which are consistent with Pulmonary Embolism (PE) including McGinn White sign, a classic sign of PE. However, due to previous history, the treating team diagnosed the patient with gastroenteritis. The patient was given intravenous fluids, but their heart rate failed to respond.

Over the next few days the patient complained of pain and swelling in their lower limbs and a diagnosis of DVT was made. Despite further treatment, the patient’s haemodynamic parameters worsened. Further tests were ordered, but before they could be carried out, the patient suffered a cardiac arrest.

The main learning points from this review stem from the following events:

  • The history of diarrhoea led the clinicians to a diagnosis of gastroenteritis with no alternative diagnosis considered, despite the patient presenting with symptoms indicative of a PE namely, the significant ECG abnormalities and the worsening haemodynamic parameters that did not improve with intravenous fluids.

  • The treating clinicians were influenced by the original diagnosis of gastroenteritis without acknowledging that a DVT diagnosis should be linked to the collapse, escalating hypoxia, raised troponin and classical ECG changes resulting in a missed opportunity to diagnosis PE.

  • Although the patient was reviewed numerous times, thrombolysis was not tried despite PE eventually being considered.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Ensure patients with a history of recent breathlessness and syncope prompt PE to be considered as a differential diagnosis at an early stage. Further investigations may indicate an early need to thrombolyse the patient.

  • Further training should be provided to junior doctors on the management of acutely unwell patients and the importance of identifying and explaining all presenting aspects of a patient, or to look for alternative explanations. Presenting aspects should include lack of improvement of symptoms after treatment.

  • Training should also be provided on dispassionate assessment of patients without prejudice of prior review. In this case, had the patient and prior reports from the paramedic been reviewed, independently from previous diagnosis, an alternative diagnosis may well have been made. In addition to this, it is recommended that basic ECG abnormality training is provided especially in cases of suspected PE.

  • Signs of a Pulmonary Embolism, including ECG abnormalities, should be highlighted and a cumulation of symptoms should lead to serious consideration of a diagnosis. The signs in this case were;

  • DVT diagnosis
  • Collapse
  • Escalating hypoxia
  • Raised troponin
  • Classical ECG abnormalities
  • Tachycardia with right axis deviation

  • Lastly, it is important that if CT pulmonary angiograms are delayed patients receive a treatment dose of low molecular weight heparin NICE. Had the pulmonary embolism been diagnosed sooner in this case the patient should have been moved to a Coronary Care Unit and/or High Dependency Care Unit. The delay in this case was fatal.

To Summarise

In summary, this case surrounds an incorrect diagnosis of gastroenteritis and a missed diagnosis of massive pulmonary embolism. The delay in diagnosis meant that the patient suffered a fatal cardiac arrest before an echocardiogram or CTPA could be carried out.
TMLEP would like to highlight the importance of flagging abnormal ECG findings and undertaking dispassionate assessment of patients without being influenced by previous suppositions. Signs of pulmonary embolus must not be ignored and must be viewed collectively to help form an accurate picture of the patient’s condition.

References

  • British Thoracic Society guidelines for the management of suspected acute pulmonary embolismThorax 2003;58:470-483
  • NICE Guidence https://cks.nice.org.uk/pulmonary-embolism#!scenario
  • Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group, Helen Sotillo, TMLEP Analyst and Dr Luke Smith, Consultant Acute Physician. (2020). The importance of undertaking dispassionate assessment and highlighting early indicators of a pulmonary embolism. TMLEP Clinical Risk Case Studies. 3 (7), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.