During the course of this summer three of my patients developed a well-known complication –Pulmonary embolus – a condition recognised to be more common in people with mobility impairments and in people who use wheelchairs.
What is Pulmonary Embolus?
Interestingly, they all hade spinal cord injury and presented with unusual symptoms – making diagnosis difficult. So what is pulmonary embolus?
Pulmonary embolus is a condition in which a blood clot brings about a blockage of an artery in the lungs. Pulmonary emboli are caused by clots from the venous circulation – most often originating in the legs (called deep vein thrombosis (DVT) or in the pelvic and abdominal veins. Risk factors include prolonged bed rest or inactivity, sitting for long periods (in a wheel chair), oral contraceptive use, surgery, child birth, cancer, stroke, heart attack, heart surgery, and fractures of the hips or femur. In most mobility impairments – like spinal cord injury – the risk is highest in the 3-6 months after injury – but it remains slightly elevated for life and can become even higher in hot, dry periods – especially when mobility impairment is associated with moderate or severe dehydration.
So how do you feel if you do have pulmonary embolus? Commonly most people develop: Sudden onset of cough – sometimes with some blood in the sputum. Sudden onset of shortness of breath (at rest or with exertion) or difficulty with breathing and rapid breathing. A rapid heart rate with a weak pulse, low blood pressure, fainting, dizziness or light-headedness. Sweating and anxiety. Clammy skin. Chest pain that may be situated under the breastbone or on one side, it may be sharp, stabbing, burning, aching or dull, heavy sensation, it often may be worse at night, may radiate to the shoulder, arm, neck, jaw, or other area and may be worsened by breathing deeply, coughing, eating, bending, or stooping. This may be associated with doughy swelling in one or both of the legs.
Now these symptoms can obviously be caused by any number of conditions – like pneumonia, heart problems, autonomic dysreflexia and even isolated anxiety disorder – so it is important not to jump to conclusions and to immediately discuss them with your doctor. In people with spinal cord injury the situation is often more confusing because: Sensation is disturbed or absent any chest pain may go unfelt. There may be a sudden change in spasticity, which may become much worse. There may be repeated episodes of autonomic dysreflexia. Many of the above symptoms may be confused with other symptoms associated with SCI.
In my three patients, one came in with only a severe increase in spasticity, one had isolated and unexplained autonomic dysreflexia and one had sudden onset of back pain. The pictures were not typical of pulmonary embolus – purely because of the distorted symptoms in the presence of their SCI. The important point about all of this is that untreated pulmonary embolus can lead to death (death rates are somewhere around 30%, while with treatment this drops to 3%) – and that emergency treatment and hospitalisation is necessary. If you develop these symptoms, you and your doctor need to be aware that pulmonary embolus is one of the possible diagnoses – and have a high index of suspicion. A normal chest x-ray will often not spot the problem and special test are needed.
If the condition is diagnosed, definitive treatment consists of dissolving the clot by thrombolytic therapy (clot-dissolving medication) and/or anticoagulant therapy (preventing further clot formation). Oxygen therapy is often required to maintain normal oxygen concentrations until the injury to the lungs has resolved. At the same time it is important to treat the pain, spasticity or autonomic dysreflexia associated with the embolus and remember that patients are often very weak and can take weeks to recover from the assault. As always – what is the take home message? Firstly, be aware of this condition and even remind your doctor of it if you do have any of these symptoms. Try to avoid modifiable risk factors (smoking, dehydration, prolonged confinement to bed, high dose oral contraceptives).
Ask your doctor if you need preventive treatment for deep vein thrombosis (disprin, compression stockings or even anti-clotting medication) – especially if you are hospitalised or scheduled to undergo surgery. Make sure that you ask your physio for a stretching program and do it everyday. Report any of these symptoms to your doctor.