Case of the Month
October 2004

48-year-old male — bee sting, dyspnea

You are dispatched to a 48-year-old male complaining of SOB and bee sting. The patient’s wife meets you at the door and she leads you to the bedroom where you find the patient sitting up at the edge of the bed in obvious respiratory distress with his right hand clutching the left anterior portion of his chest just under the left nipple. When asked, the patient is able to tell you in short, broken sentences that he can’t get a full breath. His skin is pale, cool and clammy. He looks terrified. He shows you a single, small red welt on his hand from the bee sting.

Your partner quickly attaches the pulse oximeter while you prepare a non-rebreathing mask. The initial oxygen saturation is 90% on room air; you start the patient on 12 liters/min. You confirm the medic unit’s ETA while giving them a short report based on the patient’s obvious respiratory distress and clinical presentation (SICK).

Your vitals and physical exam reveal the following:

RR	—	30/min, clear without wheeze
HR	—	146/min radial weak, regular
BP	—	100/60 mmHg
Skin	—	pale, warm with some cyanosis about the nails beds of his fingers; no hives or rash
HEENT	—	pupils-MER
Chest	—	symmetrical
Lungs	—	clear and equal bilateral, no wheezes
Adb	—	unremarkable
Ext	—	cast on right lower leg; small, red welt at the site of the bee sting

After a few minutes the patient’s O2 saturation increases to 93% and his respiratory effort and rate improves.

S	—	Shortness of breath/left anterior chest pain; cool, clammy skin
A	—	No known allergies
M	—	Lipitor (high cholesterol)
P	—	Gall bladder surgery five years ago. He has been laid up in bed for the past week after having surgery for a broken ankle suffered while skiing.
L	—	Candy bar for lunch 2 hours ago
E	—	Was sitting outside in the garden and was stung by a bee. The patient rose quickly and hobbled as quickly as possible to get inside. He developed SOB suddenly upon entering the house. The bee sting left only a small red welt at the site of the sting.

Based on the clinical presentation and history of the patient, it is not clear to you as to what is going on-- this doesn’t appear to be a case of anaphylaxis secondary to the bee sting. Regardless, the patient is SICK and you begin immediate and appropriate treatment. You start to suspect a possible pulmonary embolism after putting together the clinical picture and history (pale, sudden onset of SOB, chest pain on inspiration, recent surgery).

You prepare a BVM in case his respiratory status declines and arrange a rendezvous with the medic unit. You continue high flow oxygen therapy. You know your oxygen delivery is effective because of the improvement in the pulse ox reading. Your team moves the patient gently onto a gurney to avoid dislodging possible remaining emboli.

Pulmonary Embolism
Pulmonary embolus occurs when a particle such as a blood clot, fat embolus, amniotic fluid embolus, or air bubble gets loose in the blood stream and travels to the lungs. The embolus lodges in a major branch of the pulmonary artery and circulation through a large portion of the lung is interrupted thus reducing blood return to the heart and causing a reduced blood pressure. As well, blood is not able to get to the alveoli and cannot be effectively oxygenated.

The result is that less lung tissue is available to oxygenated blood and this causes dyspnea. There may be a history of immobility of lower extremities (cast or long airplane trips) or prolonged bed rest or recent surgery. Pulmonary embolism is a life-threatening condition and should be treated with high-flow oxygen and rapid transport. Move the patient gently to avoid dislodging possible remaining emboli. The ER can determine if it is an embolism and may use drugs to dissolve the clot.

The lesson learned from this case: In this case, the past medical history (no history of allergies, recent surgery) and careful observation of the patient’s signs (no hives, no wheezing, no rashes; small, red welt on skin) and symptoms (sudden onset of SOB) played an important part in the assessment of this patient. Regardless of the underlying medical condition, the quick assessment of SICK and immediate treatment with high flow oxygen, update to medic unit, and preparations to treat for shock were crucial in this case.

View index of excellent websites on pulmonary embolism — National Library of Medicine (external link)