A CASE OF MASSIVE PULMONARY EMBOLISM CAUSING VENTRICULAR FIBRILLATION AND CARDIAC ARREST

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Massive Pulmonary Embolism (PE) is a known noncardiac cause of circulatory arrest, it is associated with very poor outcomes and high mortality. We herein report a unique case of cardiac arrest due to massive PE that presented with a dominant rhythm of Ventricular Fibrillation (VF). CASE PRESENTATION: A 42-year-old male with past medical history of morbid obesity and chronic back pain; presented to our hospital with acute on chronic low back pain and inability to ambulate. On admission, vital signs were normal. Physical examination showed signs of left lower extremity radiculopathy. Often times and because of the pain severity, patient used to refuse to participate in physical therapy and assisted ambulation. Given that, patient was on appropriate pharmacological deep venous thrombosis prophylaxis. During hospitalization, the patient was found unresponsive and pulseless, code blue was activated and cardiopulmonary resuscitation was started. Upon connecting it, the cardiac monitor showed VF rhythm (Image 1) for which a shock was delivered. After few minutes, return of spontaneous circulation achieved. A 12-lead electrocardiogram demonstrated sinus tachycardia and new right bundle branch block (Image 2) and that triggered the suspicion of PE. A stat bedside echocardiogram revealed dilatation of the right ventricle. Computed Tomography of chest with intravenous contrast (PE protocol) confirmed the diagnosis of PE in the left and right main pulmonary arteries(Image 3). As a result, systemic thrombolytic therapy was initiated. Few hours later, the patient went into three successive episodes of cardiac arrest in which VF was the recurrent rhythm and multiple shocks were delivered. DISCUSSION: PE is the third most common cause of hospital-related death[1]. The vast majority of VF cases are strongly linked to cardiac events; mainly coronary artery disease due to ischemia[2]. On the other hand, PE with circulatory arrest is highly associated with pulseless electric activity (PEA) followed by asystole[3]. For VF to be the dominant rhythm in the setting of cardiac arrest due to massive PE and without any evidence of myocardial ischemia is unreported. This case highlights the importance of considering PE in the differential diagnosis of cardiac arrest causes when the presenting and the dominant rhythm is VF particularly in the absence of myocardial ischemia. CONCLUSIONS: To our knowledge, this is the first case in the literature to provide a direct link between PE and VF in the context of circulatory arrest. It is crucial to recognize the initial rhythm that is associated with the cardiac arrest as it may guide toward the etiology of the arrest. While, PEA and asystole are by far the most common rhythms in massive PE with cardiac arrest, our case should encourage physicians to also consider PE as a possible cause of cardiac arrest when VF is the main rhythm and no signs of cardiac ischemia exist. Reference #1: Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988. Br J Surg. 1991;78:849–852. [PubMed] Reference #2: Warnes CA, Roberts WC. Sudden coronary death: relation of amount and distribution of coronary narrowing at necropsy to previous symptoms of myocardial ischemia, left ventricular scarring and heart weight. Am J Cardiol. 1984 Jul 1. 54(1):65-73. Reference #3: Kürkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M, Berzlanovich A, Bankl HC, Laggner AN. Pulmonary Embolism as Cause of Cardiac ArrestPresentation and Outcome. Arch Intern Med.2000;160(10):1529–1535. https://doi.org/10.1001/archinte.160.10.1529 DISCLOSURES: No relevant relationships by Michel Chalhoub, source=Web Response No relevant relationships by halim el hage, source=Web Response No relevant relationships by Cheikh Talal El Imad, source=Web Response No relevant relationships by Ahmad Itani, source=Web Response No relevant relationships by boutros karam, source=Web Response No relevant relationships by Ahmed Mahgoub, source=Web Response No relevant relationships by chadi salmane, source=Web Response No relevant relationships by Jay Solanki, source=Web Response