EARLY MANAGEMENT OF ACUTE BILATERAL PULMONARY EMBOLISM IN A PATIENT PRESENTING WITH RECURRENT SYNCOPE

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SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Recurrent syncope is a rare presentation of pulmonary embolism that can be associated with quick deterioration and poor prognosis. Early recognition and intervention are critical to prevent early morbidity and mortality. We present this case to emphasize the importance of early thrombolytic therapy in patients presenting with syncope-associated pulmonary embolism. CASE PRESENTATION: A 43 year-old female initially presented to the emergency department with shortness of breath and syncope. She has a history of superficial DVTs, nicotine dependency, and morbid obesity. On presentation, she was alert and oriented with normal neurological findings. She had an elevated heart rate of over 120 with an oxygen saturation of 90% on 2L NC and was hemodynamically stable. Her labs were significant for leukocytosis, an elevated D-Dimer of 2.85ug/mL, BNP: 17400 pg/mL, and an initial troponin of 0.063ng/mL. An emergent chest-CT was performed which revealed large bilateral pulmonary emboli. The patient was subsequently started on full-dose Lovenox and sent to the progressive care unit for further evaluation and management. Overnight, the patient was noted to have an episode of syncope that was associated with cyanosis, tremors, and diaphoresis. At the time, her blood pressure was stable at 130/80 as she remained mildly lethargic. As the patient did not meet formal indications for systemic tissue plasminogen activator (tPA), she was immediately transferred to the ICU for further evaluation and closer monitoring of her symptoms. During the day, an echocardiogram was performed which revealed a severely dilated right atrium and ventricle with a right ventricular systolic pressure of 66.2 mmHg. The patient had fleeting episodes of bradycardia and hypotension with a noted drop of over 40 mmHg in her systolic pressure on slight movements. Given her rapid decompensation, the patient was immediately transferred to a facility capable of performing intervention catheter-directed thrombolysis for treatment. Following the transfer, the patient was pronounced deceased following complications relating to her condition. DISCUSSION: Syncope associated pulmonary embolism can be fatally attributed due to rapidly decreasing cardiac output if not treated emergently as seen in this critically ill patient. CONCLUSIONS: Syncope-associated pulmonary embolism is a medical emergency that can be associated with poor prognosis and rapid decompensation. With a 90-day mortality rate of 17.4%[1], pulmonary embolism requires heightened clinical suspicion and immediate therapy to prevent fatal pulmonary and cardiac complications. While current guidelines indicate that systemic and catheter-directed thrombolysis are reserved for those with hemodynamic instability, those presenting with recurrent syncope may predict rapid decompensation and may also benefit from early thrombolytic therapy or mechanical thrombectomy if contraindications exist. Reference #1: Altınsoy, Bülent, et al. “Syncope as a Presentation of Acute Pulmonary Embolism.” Therapeutics and Clinical Risk Management, Dove Medical Press, 27 June 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4930221/. DISCLOSURES: No relevant relationships by Khalid Sawalha, source=Web Response