Clinical characteristics of population with confirmed pulmonary embolism on ICU admission
During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%), who were all included in this study. In this study, the causes of ICU admission were: Traumatic head injury in 15 patients (44%), multiple trauma in 16 (47%), and respiratory distress in three (9%). There were 26 males (76%) and eight females (24%). The mean age (±SD) was 42.1 ± 16.3 years, with a range of 15 to 69 years. Most patients (56%) were older than 40 years. The trauma was usually caused by traffic accidents (85%). The clinical presentations of the study group on admission are shown in .
Patients’ characteristics at the time of admission to the medical intensive care unit
In our study, 32 patients (94%) had head trauma, it was isolated in 15 (46.8%). Extra-cranial pathology was present in 19 patients (56%) including fracture of long-bones in 10 (52.6%), chest trauma in 13 (38.2%), abdomen trauma in six (17.6%), pelvic trauma in four (11.7%), and spine trauma in 11 patients (32.3%). The brain CT-scan was performed in 32 patients with head trauma. It showed a meningeal hemorrhage in 20 patients (58.8%), cerebral contusion in 14 (41%), Subdural hematoma in eight patients (23.5%), extradural hematoma in four (11.8%), cerebral edema in four (11.8%), and brainstem injury in three (8.8%). A total of 32 (94%) needed intubation, mechanical ventilation, and sedation on admission.
Twenty-one patients (61.8%) had an SAPS II score of > 30, confirming the severity of the patients in the current study. Moreover, 25 patients (73.5%) had an ISS score > 25, and 31 patients (91%) had one or more organ failures on ICU admission . Neurological failure was the most common organ failure observed (79.5%), followed by respiratory and circulatory failures, observed in 53 and 38.5%, respectively. Eighteen patients (52.9%) underwent a surgical intervention before the development of thromboembolic complication. Ten patients (29.3%) required craniotomy, while nine patients (26.4%) needed extra-cranial surgery. An orthopedic surgery was applied in seven patients (20.5%).
Frequency of each organ failure on ICU admission
Clinical characteristics and investigations at pulmonary embolism diagnosis
In our study, 21 patients (61.8%) received pharmacological prevention of venous thromboembolism before development of pulmonary embolism. However, in 13 patients (38.2%) these therapies were not given because of the presence of contraindications, although, all these patients had received mechanical device for prevention of DVT. The mean delay of development of PE was 11.3 ± 9.3 days (range 3-46 days). Eight patients (24%) developed this complication within five days of ICU admission . On the day of PE diagnosis, pulmonary auscultation was performed in all patients. It was normal in 27 patients (79.4%) and showed lung crackles on auscultation of one or both lungs in four (11.7%). shows the clinical characteristics of all population groups on the day of PE diagnosis. The quantitative plasma D-Dimer dosage was performed in six patients: It was > 500 ng/l in all cases. Ultrasonography of the legs was performed in 11 patients (32.3%). It showed DVT only in five patients (45%). Chest X-ray was performed in all patients and it was normal in 17 (50%) patients. An electrocardiogram was performed in all patients. The most frequent abnormalities recorded were sinus tachycardia in 89.3% of the cases, complete or incomplete right bundle block in four patients (11.7%), and T-wave inversion over the right or the left precordial leads (T-wave inversion in leads V2–V3) in seven (20.5%). Echocardiography was performed in one (2.9%) case. It showed a left ventricular dysfunction, with neither right ventricular dilatation nor pulmonary artery hypertension. The diagnosis of PE was made by spiral CT in 33 patients (97%)  or by a V/Q scan in one (3%). Estimates of the clinical probability of PE were performed in all patients according to the two scoring systems; the Wells′ score and Geneva revised score. Only two (5.9%) patients had a high probability according to the first score and two (5.9%) patients had a high probability according to the second score .
Temporal distribution of PE incidence in 34 patients. Eight patients (24%) developed this complication within five days of ICU admission, and 14 (41%) within seven days of ICU admission
Patients’ characteristics on the day of diagnosis of PE
Chest CT scan findings of all patients on the day of diagnosis of pulmonary embolism
Probability of all patients according to the Wells and Geneva revised score
Management and outcome of pulmonary embolism
Specific treatment (anticoagulant therapy) is the mainstay of treatment. In our study, 34 patients (100%) received parenteral anticoagulants. Intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (6%). Inferior vena cava filter and thrombolysis were not used in any of the cases. Under anticoagulant therapy, three patients (9%) developed a bleeding complication, including two patients (6%) who had gastrointestinal bleeding and one patient with epistaxis. Moreover, eight patients (23.5%) developed thrombocytopenia. The mean ICU stay was 31.6 ± 35.71 days (range: 1-203 days) and the mean hospital stay was 32.77 ± 35.31 days (range: 3-205 days). During their ICU stay, 32 (94%) patients developed one or more organ failures. Respiratory failure was the most commonly observed (29.4%) followed by cardiovascular failure (23.6%). Furthermore, 27 (79.4%) developed nosocomial infections. The mortality rate in the ICU was 38.2% (13 patients) and the in-hospital mortality rate was at 41% (14 patients). Univariate analysis showed that factors associated with poor outcome were: Shock (P = 0.003), age > 55 years (P = 0.014), and a number of organ failures > 3 (P = 0.02). shows factors associated with poor outcome in the ICU. The multivariate analysis showed that factors associated with poor prognosis were the presence of circulatory failure (Shock) (P = 0.02; Odds ratio (OR) = 9.96; 95% CI = 1.4-70) and thrombocytopenia (P = 0.028; OR = 32.5; 95% CI = 1.45-72.5). The in-hospital mortality rate was at 41% (14 patients). Factors associated with poor hospital outcome were the presence of circulatory failure (Shock) (P = 0.004; Odds ratio (OR) = 8.4; 95% CI = 1.1-65), and a number of organ failures associated with PE ≥ 3 (P = 0.002, OR = 3.7; CI: 1.4-31).
Factors associated with a poor outcome in ICU on univariate analysis
Predictive factors of pulmonary embolism
As previously shown, during the study period, we included a second group of 42 trauma patients without clinical manifestations of PE (in this group, pulmonary thromboembolism was not suspected by our medical staff). Comparison between the two groups showed that factors associated with PE in univariate analysis were: Age > 40 years (P = 0.03), SAPS II > 25 (P = 0.013), the presence of meningeal hemorrhage (P = 0.004), the presence of spine fracture (P = 00.005), hypoxemia with PaO2/FiO2 < 200 (P = 0.0054), and a platelet level > 150 cells/mm3 (P = 0.049) . Multivariate analysis showed that factors associated with PE were: Age > 40 years (P = 0.038, OR: 4.57, and 95% CI: 1.08-19.2), a SAPS II score > 25 (P = 0.046, OR: 4.48, and 95% CI: 1.02-19.6), hypoxemia with PaO2/FiO2 < 200 (P = 0.025, OR: 1.26, and 95% CI: 1.26-31), the presence of spine fracture (P = 0.007, OR: 13.6, and 95% CI: 2-93), and the presence of meningeal hemorrhage (P = 0.001, OR: 12.8, and 95% CI: 2.7-60).
Factors associated with pulmonary embolism in univariate analysis