I'm working on presenting a recent case and wanted to get some feedback. Male pt mid 30's presents the day before with a closed comminuted and displaced tib/fib fracture. Doesn't remember how it occurred (etoh 399 and +cocaine). Surgery to repair occurs the next day. Smooth induction and easily intubated. After moved to OR table and dressing removed become dusky and pale with unobtainable BP or pulse ox. HR 130's, SBP 60. EtCO2 around 8 at this time. Weak carotid pulse present. EPI and NEO with adequate response in BP. ETT confirmed with glidescope and fiberoptic with no signs of aspiration. PT given 5000U heparin and sent to CT. CT scan negative for PE but did have aspiration of the right main bronchus and collapse of RUL.

PT remained stable and was able to have leg fixed later that day uneventfully. After reviewing all of the pt's chart it seems unlikely that RUL pneumonitis caused this event. I think it is also probable that the pt had this aspiration before admission given that he was severely intoxicated and no signs of aspiration were noted during induction.Is it possible to have enough microemboli that could cause PE symptoms this severe? Might they have become dislodged during transport? Is there another explanation that I could be overlooking?

Thanks for the help!