Abstract
We describe the successful cardiopulmonary resuscitation of a patient with massive pulmonary embolism who received thrombolysis via the intraosseous route. This case also demonstrates survival without apparent long-term sequelae despite extreme metabolic acidosis. In the context of pulmonary embolism, this has not been widely reported in the existing literature. A 22-year-old woman suffered a prolonged cardiac arrest secondary to pulmonary embolism in a hospital corridor following short hospital admission for medical termination of pregnancy. A point-of-care echocardiogram showed a grossly dilated right ventricle indicative of pulmonary embolism. Due to severe peripheral vasoconstriction, intravenous access proved difficult, and the decision was made to deliver intraosseous thrombolysis. Initial blood gas analysis showed a profound acidosis due to alternating return of spontaneous circulation and further loss of output. Because of her prolonged "low-flow" state, she was deemed unsuitable for extracorporeal membrane oxygenation. Despite the poor prognosis, the decision was made to continue with resuscitation in light of a reversible pathology. She was successfully discharged from the hospital after a short intensive care stay with no long-term complications. This case demonstrates successful thrombolysis through an intraosseous route, with a good outcome despite poor prognostic factors. Early thrombolysis and continuous cardiopulmonary resuscitation in massive pulmonary embolism are imperative to survival in cardiac arrest.
Highlights
Thrombotic events are common in obstetric patients, occurring up to ten times more frequently than in the general population
Several countries have reported that the incidence has had an increasing trend over the past two decades. This may be due to increasing numbers of patients surviving severe comorbidities, such as malignancy, which carry a higher risk of developing venous thromboembolism (VTE)
This case illustrates that the complexity of managing critically unwell patients outside of the intensive care unit can be mitigated by good quality, uninterrupted cardiopulmonary resuscitation (CPR) to increase forward blood flow and maintain adequate perfusion to end-organs
Summary
Thrombotic events are common in obstetric patients, occurring up to ten times more frequently than in the general population. We present a case of massive PE leading to cardiac arrest in a patient following medical termination of pregnancy. She underwent successful thrombolysis during cardiopulmonary resuscitation (CPR) and, despite 13 cycles of CPR and over an hour in a “low-flow” state, survived to discharge with no evidence of neurological impairment. A 22-year-old woman of nine weeks gestation was admitted to the gynecology ward for medical termination of pregnancy She was discharged two hours following the procedure. Vasopressor and inotrope support were successfully weaned, and the ischaemic liver and kidney injury started to resolve She was stepped down to the high dependency unit and discharged from the hospital after 14 days
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