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Abstract

Introduction: Background: Patients with pulmonary embolus (PE) who require cardiopulmonary resuscitation (CPR) have an overall mortality as high as 65%; up to 20% of patients present in pulseless electrical activity (PEA), but only 4% survive to discharge. Hemodynamic instability, renal failure, or pregnancy precludes CT angiogram (CTA). Bedside echocardiography (BE) is a diagnostic tool to guide treatment in hemodynamically unstable patients. We present a patient in PEA with severe acidosis diagnosed with PE by BE who received tissue plasminogen activator (tPA) and was discharged neurologically intact. Case Report: A 50-year-old female was brought to the emergency department for sudden onset of dyspnea, palpitations, and syncope. History was notable for a left lower extremity fracture casted three weeks earlier and tobacco use. Physical exam showed an ill-appearing, obese female in respiratory distress with sinus tachycardia, pulse 162, blood pressure (BP) 122/61, respiratory rate 42, and oxygen saturation (O2 sat) 96% on room air. The patient decompensated and became bradycardic with pulse 50, BP 93/70, and O2 sat 79%. CPR was started; the patient was intubated and return of spontaneous circulation was achieved. Arterial blood gas revealed: pH 6.73, pCO2 85, HCO3 11, pO2 107. D-dimer was >4,000 ng/mL. BE demonstrated ejection fraction of >65%, right ventricle (RV) enlargement, and moderate RV systolic dysfunction. Electrocardiogram (ECG) showed sinus tachycardia with a new right bundle branch block. In the intensive care unit (ICU) she went into PEA on three occasions. 100mg of tPA was administered for massive pulmonary embolism, which was halted after 50mg given concerns for hemorrhage. PE was confirmed by CTA on hospital day (HD) #4. The patient was extubated on HD #4 with no neurologic deficits, and was discharged on HD #18. Discussion: BE is an invaluable tool to diagnose and treat PE in patients with hemodynamic instability or contraindication for traditional confirmatory studies. BE indicators of massive PE include: direct visualization of a thrombus, RV hypokinesis, <50% inferior vena cava collapse during inspiration, RV dysfunction with akinesia of the mid free wall with normal apical motion, and interventricular septal flattening or paradoxical LV motion. Despite the paucity of randomized trials showing benefit of thrombolytic in treating all patients with PE, thrombolytic therapy has been shown beneficial and should be used in patients with high likelihood of death, RV dysfunction, or hemodynamic instability.