ACUTE PULMONARY EMBOLISM and chronic DEEP VENOUS THROMBOSIS in a POLYTRAUMA PATIENT: Role of bed-side ULTRASOUND

INTRODUCTION
Pulmonary embolism (PE) often occurs in polytrauma patients due to the hypercoagulability state as well as immobilization. It is considered the third cause of mortality in a traumatic patient who survives 24 hours to the accident. It is unusual to diagnose PE immediately in the initial assessment of the patient. A case of a trauma patient with a PTE diagnosed at admission, presumably due to trauma of a thrombus in the same anatomical area where he had chronic deep vein thrombosis (DVT), is reported. The importance of early diagnosis of PE and/or DVT by bed-side ultrasound, leading to therapeutic implications, is emphasized. 

CASE DESCRIPTION
A 51-year-old male patient who had a motorbyke accident presented with a Glasgow Coma Scale of 15, hemodynamically stable and good gas exchange. Initial pulmonary ultrasound showed a pattern of A-lines with preserved sliding. The posterior CT scan showed an acute PE involving right lobar branches with right sacroiliac joint dislocation, and right femoral fracture. Lower limb venous doppler ultrasound showed a non-permeable and non-compressible distal right superficial femoral vein and popliteal vein, with a chronic thrombus visualised. Osteotaxis of the pelvis and femoral transkeletal traction were urgently performed. An inferior vena cava (IVC) filter was inserted. Intramedullary nailing of femoral fracture and osteosynthesis with plate of pubic symphysis and sacroiliac screws was performed. After 10 days, anticoagulation dose with tinzaparin was initiated and planned to be maintained for 6 months. Patient was transfered to a rehabilitation center.

DISCUSSION
The diagnosis of PTE immediately after trauma is uncommon and should lead to suspicion of thrombus release. Ultrasound allows bed-side early diagnosis of several potentially fatal entities in the trauma patient. In this case it was useful for the diagnosis of DVT, whose diagnosis had therapeutic and prognostic implications. The diagnosis of DVT with contraindication for immediate anticoagulation led to IVC filter insertion.

Acute pulmonary embolism and chronic deep venous thrombosis in a polytrauma patient: role of bed-side ultrasound