76) A 65 year-old man with history of recently diagnosed metastatic colon cancer being treated with chemotherapy is admitted to the hospital with constipation and vomiting. His colon cancer was diagnosed by colonoscopy 2 months ago when he presented with massive GI bleeding. At this admission, patient is diagnosed with bowel obstruction secondary to descending colon cancer and underwent a palliative left hemicolectomy to provide symptomatic relief. He has no occult or gross GI bleeding at this time. On the sixth post-operative day, you are called by the nurse because the patient’s blood pressure is 80/40. His heart rate is 82, respiratory rate 24 and temperature of 100.6. The patient is given Normal saline bolus. A CXR is normal. EKG reveals a prominent S wave in lead I, a Q wave and inverted T wave in lead III. Of note, a pre-operative EKG was completely normal. First set of cardiac enzymes are negative. A bedside 2D echo reveals global hypokinesis of the right ventricle. A repeat blood pressure obtained after normal saline bolus is still low at 70/40. The most likely etiology of the shock in this patient is :
A) Hypovolemia
B) Septic shock
C) Acute myocardial infarction leading to cardiogenic shock
D) Acute pulmonary embolism
E) Tension Pneumothorax
77) Most important next step in treating this patient’s shock?
A) Continued fluid boluses
B) Antibiotics and pressor support with dopamine
C) Intra-aortic balloon counter-pulsation followed by urgent cardiac catheterization.
D) Anticoagulation with heparin
E) Tissue plasminogen activator ( tpA)
F) Embolectomy
G) Chest tube placement.
H) Inferior vena cava filter
78) The patient was appropriately treated. The discharge recommendations should include :
A) Inferior venacava filter
B) Life-long low-molecular weight heparin
C) Life-long coumadin
D) Hypercoagulability testing
E) Compression stockings
Archer USMLE Step 3 Blog 
D, F, C
D F C
DFC
D,E,C
The currently accepted indications for thrombolytic therapy include hemodynamic instability or right ventricular dysfunction demonstrated on ECHO.
In patients with submassive acute pulmonary embolism, either catheter embolectomy or surgical embolectomy may be considered if they have clinical evidence of an adverse prognosis (ie, new hemodynamic instability, worsening respiratory failure, severe right ventricular dysfunction, or major myocardial necrosis). These interventions are not recommended for patients with low-risk or submassive acute pulmonary embolism who have minor right ventricular dysfunction, minor myocardial necrosis, and no clinical worsening
The current ACCP guidelines recommend that all patients with unprovoked pulmonary embolism should undergo a risk-to-benefit evaluation to determine if long-term therapy is needed (grade 1C). Long-term treatment is recommended for these patients who do not have risk factors for bleeding and in whom accurate anticoagulant monitoring is possible (grade 1A).
Patients who have pulmonary embolism and preexisting irreversible risk factors, such as deficiency of antithrombin III, protein S and C, factor V Leiden mutation, or the presence of antiphospholipid antibodies, should be placed on long-term anticoagulation.
Dr Archer,
Could you please clarify why it is not sufficient to treat this patient only for 1 year-as he has not got any thrombophilia.
For PE we need to heparise intially, followed by warfarin-do we then not say long term warfarin traetment?
Thank you
D, F, B.
Anticoagulation for prophylaxis against recurrent VTE should generally be avoided if there is active bleeding and/or there are other contraindications to anticoagulant use (eg, recent surgery, pre-existing bleeding diathesis, platelet count <50,000/microL, coagulopathy)
2008 ACCP Guidelines: initiate treatment with LMW heparin for the first three to six months. Because the risk of recurrent VTE is unacceptably high in patients with active cancer who stop anticoagulant therapy, it is suggested that subsequent treatment with either LMW heparin or warfarin be given indefinitely or until the cancer is resolved.
For patients with malignancy, a reasonable quality of life and life expectancy, and venous thromboembolism, we suggest initial treatment with LMW heparin over the use of oral anticoagulants
For selected high risk general surgery patients, including those who have undergone major cancer surgery or have previously had VTE, we suggest that continuing thromboprophylaxis after hospitalization with LMW heparin for up to 28 days be considered
C,D , C
sorry, is C,E,C
DFB. tPA contraindicated. LMWH long term since cancer.
D, F, A ( Anticoagulation is contraindicated in recent surgery, so upon discharge, the patient must have already a IVCF ).
This is a very interesting question. I would love to know the correct answer.
I’m thinking DFA as well.
bleeding in this case of PE is a CI to Rx with tPA/heparin/warfarin.
1) PE
2) tPA contraindicated → EMBOLECTOMY
3) heparin/warfarin contraindicated → IVC filter
since vitals are unstable tPA or in this case embolectomy is a better choice than heparin/warfarin.
actually, heparin/warfarin may not be contraindicated because the surgery was 6 days ago. Major abdominal surgery in past 2 days is a relative contraindication according to Archer notes. Dr. Red, any comments?
VTE contributes to morbidity and is one of the leading causes of noncancer death among patients with cancer–Chemotherapy is associated with a 2- to 6-fold increased risk of VTE referenced to the general population –Cancer patients are at high risk of VTE, especially in the setting of immobility, hospitalization, or surgery–Many consider LMWH as the agent of choice for the initial and long-term treatment of VTE in patients with neoplastic disease,–It is worth noting that patients receiving LMWH for extended periods are at increased risk for osteoporosis, monitoring these patients with bone mineral density studies, and considering interventions (e.g., bisphosphonates) as appropriate.–this PT has PE need Embolectomy and llong-term Tx with LMWH–
D F A
Why not Inferior vena cava filter instead of LMWH. and is written in American board or European book ‘ General Trauma Care and Related Aspects: Trauma Surgery II edited by Hans-Jörg Oestern, Otmar Trentz, Selman Uranues’. kindly reply