M.M., a 76-year-old retired schoolteacher, underwent open reduction and internal fixation (ORIF) for a

fracture of his right femur. His preoperative control prothrombin time (PT/INR) was 11 sec/1.0 and his

aPTT was 35 seconds. He has been on bed rest for the first 2 days postoperatively. At 0600, his vital signs were 132/84, 80 with regular rhythm, 18 unlabored, and 99 F (37.2 C). He is awake, alert, and oriented with no adventitious heart sounds. Breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present, and he is taking sips of clear liquids. An IV of D5 NS is infusing 75 mL/hr in his left hand and orders are to change it to a saline lock in the morning if he is able to maintain adequate PO fluid intake. He has orders for oxygen (O 2 ) to maintain Sa O 2 over 92%. His lab work shows Hct, 34%; Hgb, 11.3 mg/dL; K, 4.1 mEq/L; aPTT, 44 sec. Pain is controlled with morphine sulfate 4 mg IV as needed every 4 hours, and he has promethazine (Phenergan) 25 mg IV q3h if needed for nausea. He is also receiving heparin 5000 units subcutaneously bid, taking docusate sodium (Colace) PO once daily, and wearing a nitroglycerin patch.

At 2330 on the second postoperative day, you answer M.M.'s call light and find him lying in bed breathing rapidly and rubbing the right side of his chest. He is complaining of right-sided chest pain and

appears to be restless.

You check his vital signs, with these results: BP 98/60; P 120; R 24. In addition, you note that he is restless and slightly confused. The pulse oximeter reads 86%, so you start him on 6 L O 2 by nasal cannula. You identify faint crackles in the posterior bases bilaterally; you recall that the lungs were clear this morning. The heart monitor on lead II shows nonspecific T-wave changes.

You evaluate the room air ABG results.

Chart View

Arterial Blood Gases

pH -------------------------------------- 7.55

PaCO2 ------------------------------------------------------------ 24 mm Hg

HCO3 ------------------------------------------------------------ 24 mEq/L

PaO2 ------------------------------------------------------------- 56 mm Hg

SaO2 ------------------------------------------------------------ 86% (room air)

Vital Signs

Blood pressure ------------------- 150/92 mm Hg

Heart rate -------------------------- 110 beats/min

Respiratory rate ------------------ 28 breaths/min

Temperature ---------------------- 99 F (37.2 C)

The chest x-ray showed a small right infiltrate. The physician suspects an embolism, either fat or pulmonary, and orders a STAT ventilation/perfusion ( V/Q ) lung scan. The interpretation of the results reads "strongly suggestive of a pulmonary embolus (PE)."

The physician decides not to administer an antidote, and M.M. is monitored closely. Four hours later, the

aPTT is 40 seconds.

1. Make the concept map