A 73-year-old man presented to the ED with confusion. He had a history of atrial fibrillation complicated by ischemic stroke and a history of DVT with placement of an inferior vena caval filter. His primary care physician had discontinued anticoagulants because of repeated falls. On presentation, his admission chest radiograph revealed opacity of the left lower lobe. He received antibiotics for suspected community-acquired pneumonia.
On hospital day 2, the patient developed increased respiratory distress and was transferred to the medical ICU (MICU) for impending respiratory failure. Upon arrival to the MICU, the resident attempted to place a central venous catheter in the left internal jugular vein under ultrasound guidance, but this was malpositioned and removed. As part of the workup for progressive respiratory failure, CT angiography of the chest confirmed the presence of a pulmonary embolism in the anterior segment of the left upper lobe. The MICU team began treatment with unfractionated heparin. On hospital day 4, the patient’s hemoglobin level decreased from 13.6 g/dL to 7.9 g/dL and chest radiograph showed near complete opacification of the left hemithorax (Fig 1).