Diagnosis Of Massive Pulmonary Embolism Research Articles

Massive Venous Air Embolism in a Case of Hysteroscopy: A Rare Grave Complication in a Comparatively Simple Procedure

Hysteroscopic surgery has gained popularity but lethal complication like gas or venous air embolism can occur. It can be recognized by a decrease in oxygen saturation and sudden drop in end-tidal carbon dioxide and may sometimes lead to severe organ failure and death depending on the amount of air embolism. We report the case of a 55-year-old female with no comorbidities posted for evaluation of postmenopausal bleeding by diagnostic hysteroscopy. The procedure was performed under spinal anesthesia using normal saline as distending media. Midway between the procedures, the patient developed severe bradycardia and desaturation. Hence, with the diagnosis of massive pulmonary embolism, the patient was resuscitated but could not be revived. The fatal outcome from a comparatively simple procedure is not uncommon. Complications are to be kept in mind and possible precautionary measures are to be taken at all times. As the eye cannot see what the mind does not know.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient’s clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Case Report: Role of transesophageal echocardiography in a patient with an initially misdiagnosed acute pulmonary embolism

Background: For the diagnosis of acute pulmonary embolism, chest computerized tomography (CT) angiography is considered as the gold standard. However, echocardiography could be useful especially in cases of high suspicion with normal CT scan or for patient with hemodynamic instability. Case presentation: We present a case of a 47-year-old man admitted to the intensive care unit with a diagnosis of respiratory failure and hemodynamic instability 24 hours after closed fracture of the right leg. Before his admission, a thoracic CT angiography was done but did not show any sign of acute pulmonary embolism. During the first hours, he presented a bad evolution with a respiratory status which failed to respond to high dose of vasopressor, oxide nitric and ventilatory support. Therefore, due to the poor echocardiographic window, transesophageal echocardiography examination was done in emergency. It revealed high-probability diagnosis of massive pulmonary embolism based on right ventricular dysfunction and the presence of thrombus in the right pulmonary artery. Anticoagulant therapy (non-fractioned heparin) was administrated immediately achieving a favorable clinical outcome with rapid withdrawal of dobutamine, nitric oxide and norepinephrine. Conclusions: This case illustrates the fundamental role of transesophageal echocardiography in a critically ill patient with shock due to high-probability pulmonary embolism. Echocardiography allows the initiation of adequate treatment without further delay.

PULMONARY EMBOLISM CASES WHICH OCCURRED UNDER ENOXAPARIN SODIUM 4000 IU PROPHYLAXIS

TOPIC: Pulmonary Vascular Disease TYPE: Global Case Reports INTRODUCTION: Some surgical based guidelines recommends standart 4000 IU Enoxaparin for VTE prophylaxis. However fixed dose enoxaparin will often fail to achieve therapeutic levels, since for therapeutic anticoagulation, enoxaparin is dosed based on weight (1mg/kg). To draw attention to this issue, we presented 3 cases who developed PE while receiving 4000 IU Enoxaparin prophylaxis. CASE PRESENTATION: Cases Case 1:A 27-year-old, 72 kilogram male patient, who had no known chronic disease history, was using Enoxaparin sodium 4000 international units (IU) regularly once a day after the meniscus operation. Complaints of back pain and shortness of breath developed two weeks after the operation In the computed tomography pulmonary angiography(CTPA), filling defects in the middle and lower lobar branches of the right lung and extending to the lingular segment of the upper lobe of the left lung were seen. The patient was followed up in our department with the diagnosis of bilateral lobar pulmonary embolism (PE).Case 2:An 80-year-old 65-kilogram female patient with a known chronic obstructive pulmonary disease, atrial fibrillation (AF), hypertension, was using a new generation oral anticoagulant (NOAC) due to AF. NOAC was discontinued upon the development of ecchymotic lesions in the body, and Enoxaparin sodium 4000 IU was added to the treatment once a day.. Three weeks after the treatment change, the patient was admitted to the emergency department with the complaint of dyspnea, and a thrombus extending from the distal of both main pulmonary arteries to the bilateral lower and upper lobe bronchial artery was detected in the CTPA, and he was followed up in our service with the diagnosis of massive PE. DISCUSSION: Case 3: An 81 years old, 67-kilogram female patient with a diagnosis of hypertension and Alzheimer's disease admitted to the hospital with complaints of shortness of breath and swelling in the legs for a week. Seven months ago, Enoxaparin sodium 4000 IU was planned twice a day in an external center due to pulmonary embolism. The patient continued to use LMWH 4000 IU once a day after the 3rd month of his own request. CTPA revealed filling defects in the right pulmonary artery upper lobe posterior and lower lobe posterobasal segments. Lower extremity venous Doppler ultrasonography revealed deep vein thrombus (DVT). When compared with previous examinations, it was observed that pulmonary embolism had newly developed and the patient was followed up with segmental PE + DVT diagnoses. CONCLUSIONS: Although low-dose LMWH treatment is recommended in some guidelines and drug package insert for PE prophylaxis, the cases we have presented suggest that it would be safer to consider the patient's weight when administering LMWH prophylaxis. REFERENCE #1: Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature SearchVan N Tran 1, Ilya Varfolomeev 2, Geoff Hill 3 DISCLOSURES: No relevant relationships by MELTEM GUNDUZ, source=Web Response No relevant relationships by H.Canan Hasanoglu, source=Web Response

Massive pulmonary embolism presenting with hemoptysis and S1Q3T3 ECG findings

BackgroundVenous thromboembolism clinically presenting with a deep vein thrombosis or pulmonary embolism is among the most commonly seen cardiovascular syndromes. The aim of this case presentation is to emphasise the typical electrocardiographic findings that are detected with massive pulmonary embolism along with the electrocardiographic S1Q3 and S1Q3T3 accompanied by T negativity at the D3 derivation based on prevalent T negativity.Case presentationWe present the case of an adult male who presented with a massive pulmonary embolism that was associated with tachycardia, haemoptysis and typical S1Q3T3 electrocardiographic findings. Tomographic findings showed filling defects in the two main pulmonary artery lumens, which were found to be compatible with a massive embolism. Intravenous heparin was injected (5000 IU), and low molecule weight heparin (LMWH) treatment was initiated. After two days of observation and treatment in the coronary intensive care unit, the patient was discharged for outpatient care.DiscussionMassive pulmonary embolism is an urgent life-threatening clinical situation that is frequently confused with acute ST elevation myocardial infarction. The definitive diagnosis of massive pulmonary embolism was made with a computed tomography pulmonary angiogram. Electrocardiographic findings and hypoxic hypercarbia in the blood gas analysis are typical. Early diagnosis with laboratory and imaging investigations is vital in the treatment and prognosis of pulmonary embolism.ConclusionsVentricular overload signs accompanied by ST segment elevation in electrocardiography and S1Q3 and prevalent T negativity are crucial features in terms of distinguishing between pulmonary embolism and myocardial infarction and selecting effective treatments for patients admitted to the emergency department.

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study.

BackgroundThere is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries.ObjectiveTo assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard.MethodsThe patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY).ResultsThere were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%.ConclusionPositive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.

Is Thrombolytic Therapy appropriate at the Late Phase of Cardiopulmonary Resuscitation for Massive Pulmonary Thromboembolism?

Pulmonary thromboembolism in which hemostatic balance is disrupted is a disease with high morbidity and mortality rates with challenging diagnosis. A 73-year-old female patient presented to the emergency department with respiratory distress. She had undergone surgery for femoral neck fracture three months ago. She had gradually aggravating respiratory distress for the last 3-4 days. The patient was admitted to the hospital with the diagnosis of massive pulmonary embolism. She had a cardiac arrest after completion of thoracic computed tomography (thoracic CT). Cardiopulmonary resuscitation (CPR) was initiated. Alteplase (rt-PA) was infused at 100 mg/2 hours starting at the 37th minute of CPR in the late phase. As there was no room on the wards, she was admitted to the emergency room observation unit and extubated on the 9th day. Coumadin (warfarin) dose was adjusted and the patient was discharged on day 17 with an INR (International Normalized Ratio) of 2.3.

The Results of Thrombolytic Treatment in Patients With High-risk Pulmonary Embolism

Abstract Background: Mortality rates due to massive pulmonary embolism (PE) are much higher than estimated. Although thrombolytic therapy is controversial, it can be a life-saving procedure and can be safely used in patients with massive PE. Study aim: We aimed to share the results of thrombolytic treatment in patients with massive PE. Material and methods: We retrospectively evaluated 72 patients with PE admitted between January 2010 and April 2018 to the Department of Pulmonary Medicine, VM Medicalpark Samsun Hospital, Samsun, Turkey. The data of patients who received thrombolytic treatment were retrospectively analyzed. Results: The female to male ratio was 24/48, with a mean age of 62.7 ± 12.6 (minimum 27, maximum 88) years. The diagnosis of massive PE was established with echocardiography in all patients and was confirmed via pulmonary CT angiography in 45 patients (62.5%) who presented an appropriate clinical status for this imaging technique. The most common symptoms were dyspnea (90.3%), chest pain (83.3%), and syncope (40.2%). The S1Q3T3 electrocardiography pattern was noted in 82% of patients, who rapidly recovered after thrombolytic therapy. Cardiopulmonary arrest was seen in 25 patients (37.2%), and thrombolytic treatment was administered during cardiopulmonary resuscitation in 18% (n = 13) of patients. The survival rate was 30.7% (n = 4) in patients with cardiopulmonary arrest who received thrombolytic treatment in the emergency room. The complications of rt-PA treatment included minor hemorrhages in 6.4% (n = 5), major hemorrhages in 2.7% (n = 2), and allergic reactions in 1.3% (n = 1) of patients. None of the patients had deceased as a complication of thrombolytic treatment. The overall mortality rate was 26.2% (n = 19), and 12.5% (n = 9) of the patients have died in first 24 hours after thrombolysis. Conclusions: We concluded that the risk factors, ECG, and echocardiography are key indicators for the suspicion of massive PE in patients with hemodynamic shock. Based on our experience, early thrombolytic therapy is a life-saving intervention in patients with diagnosed and/or suspected massive PE.

Thrombolysis during Extended Cardiopulmonary Resuscitation for Autoimmune-Related Pulmonary Embolism

Massive pulmonary embolism (MPE) is one of the potentially reversible causes of cardiac arrest and pulseless electrical activity. At present, a fear of lethal haemorrhage makes thrombolytic therapy prohibitive during cardiopulmonary resuscitation. Blood hypercoagulability in autoimmune disorders (such as autoimmune haemolytic anaemia) carries a risk of MPE. Prompt diagnosis is critical for timely thrombolytic intervention. We reported a 23-year-old female with 10 years medical history of autoimmune haemolytic anaemia developed cardiac arrest in our emergency intensive care unit. Electrocardiogram and echocardiogram findings indicated the possibility of MPE, so fibrinolytic therapy with alteplase was administered along with prolonged cardiopulmonary resuscitation. Her neurological recovery was generally good, and no major bleeding occurred. MPE was confirmed by computed tomography pulmonary angiography afterwards. We regard that once there is presumptive diagnosis of MPE, initiating early thrombolysis during cardiopulmonary resuscitation may be considered. (Hong Kong j.emerg.med. 2016;23:180-185)

John H Gibbon Jr Lecture. Extracorporeal life support: Gibbon fulfilled.

In December 1992, a young woman was brought to the emergency room at University of Michigan Hospital with acute shortness of breath and shock. She was stabilized and sent to the radiology suite with a presumptive diagnosis of massive pulmonary embolism. A CT scan demonstrated a very large saddle pulmonary embolism. She arrested in radiology and the extracorporeal membrane oxygenation (ECMO) team was called during CPR. She was placed on venoarterial extracorporeal life support (ECLS) and was supported with that device for the next 5 days. During that time the clot lysed, her right ventricular failure resolved, her gas exchange improved, and she was ultimately discharged with good heart and lung function. Twenty-one years later, she was in attendance at the American College of Surgeons Gibbon Lecture and met the surgeons assembled for that presentation. At Michigan, we managed 16 cases of massive pulmonary embolism with ECLS between 1992 and 2006, thirteen had a healthy survival (80%). In February 1931, a young woman suffered a massive pulmonary embolism at the Massachusetts General Hospital. The resident on duty was a 26-year-old research fellow in Dr Edward Churchill’s laboratory named John Gibbon. Dr Gibbon was pursuing a research year during his surgical residency at the Pennsylvania Hospital in Philadelphia. Like many residents in the laboratory, he was pressed into clinical service and was responsible for the care of that young woman. Young Dr Gibbon is shown with Dr Churchill’s laboratory technician in Figure 1. Dr Gibbon attended to that patient throughout a long night, but her vital signs deteriorated and she died early in the morning. Dr Gibbon’s description of the events of that night is an eloquent example of what would now be described as the beginning of translational surgical research (Fig. 2). Dr Gibbon recorded “.the idea naturally occurred to me ‘that extracorporeal circulation should be possible.’” Every surgeon sees unsolved clinical problems every day, and every surgeon thinks “it naturally occurred to me” that there should be a solution to the

Life-saving percutaneous intervention in young patient with massive pulmonary embolism

Massive pulmonary embolism (PE) is not an uncommon condition, and it usually carries a high risk of mortality. It is one of the fatal conditions that commonly affect young patients. A definitive treatment for patients with massive PE is still lacking, and surgical intervention carries a substantial mortality risk. Thus, percutaneous intervention (clot fragmentation and/or aspiration) remains an option in some patients, specifically in those with a risk of bleeding, contraindicating the use of thrombolysis. There have been no randomized trials to validate percutaneous intervention in massive PE. A sufficient level of evidence is still lacking, and its use depends upon the expert committee’s opinion and study of previous case reports. We present a 23-year-old man with first onset massive PE secondary to protein C deficiency, who was treated successfully with the combination of systemic thrombolysis and percutaneous interventions.

Emergency department bedside echocardiography diagnosis of massive pulmonary embolism with direct visualization of thrombus in the pulmonary artery

Abstract A 62-year-old woman presented to the emergency department (ED) with a chief complaint of 3 weeks of progressively worsening shortness of breath. Her physical examination was normal, except for tachypnea. Her lungs were clear, and no murmurs, gallops or rubs were heard on the cardiac examination. ED bedside echocardiography with color, continuous wave and tissue Doppler ultrasound imaging and lower extremity ultrasonography performed by an ED attending physician revealed a massive pulmonary embolism with right ventricle pressure overload, tricuspid and pulmonic regurgitation, right atrial thrombus and a right popliteal thrombus. The right ventricular outflow tract view allowed for the direct visualization of thrombus in the pulmonary artery. Bedside echocardiography with color, continuous wave and tissue Doppler ultrasound imaging and lower extremity compression ultrasonography can assist the emergency physician and the critical care physician in the diagnosis of massive pulmonary embolism and deep venous thrombosis. Direct visualization of embolic thrombus in the pulmonary artery can help the ED physician accelerate both medical intensive care consultation and therapy and surgical consultation for possible thromboembolectomy and inferior vena cava filter placement.

Sonographic diagnosis of pulmonary embolism with cardiac arrest without major dilation of the right ventricle or direct sign of lower limb venous thrombosis

Bedside focused echocardiography diagnosis of massive pulmonary embolism during cardiac arrest is mainly based on the detection of a dilated right ventricle, while the lack of compressibility of a deep vein of the lower limbs confirms diagnosis in doubtful cases. We describe a case of unusual sonographic signs in a young woman with cardiac arrest due to massive pulmonary embolism showing spontaneous blood echogenicity in the inferior vena cava ("sludge sign") and nonmodulated ("flat") Doppler waveform in the left lower limb veins, suggesting isolated iliac vein thrombosis.

Association of mechanical chest compression and prehospital thrombolysis

Pulmonary embolism (PE) is a common cause of sudden death; the use of prehospital thrombolysis is currently a last-resort option and requires a prolonged cardiopulmonary resuscitation (CPR). Novel mechanical devices have recently been introduced that provides automatic mechanical chest compression (AMCC) according to the guidelines and continually without decrease efficiency throughout prolonged resuscitation. A 54 year-old woman with a history of breast cancer experienced sudden chest pain and severe dyspnea. A mobile intensive care unit was dispatched to her home. During physical examination, she suddenly collapsed with pulseless electrical activity as the initial rhythm. Prehospital thrombolysis during CPR combined with use of AMCC was performed based on a strongly suspected diagnosis of massive PE. After 75 minutes of effective CPR, return of spontaneous circulation was attained. After admission to an intensive care unit, computed tomographic scan confirmed bilateral PE. The patient was discharged 3 weeks after CPR in good neurologic condition. To our knowledge, this is the first case describing combined use of thrombolysis and AMCC in out-ofhospital cardiac arrest. However, for the time being, prehospital thrombolysis in CPR continues to be a measure that should only be performed on a case-by-case basis based on informed decision. Further studies are needed to evaluate the efficacy and safety of AMCC with thrombolysis and thus prolonged CPR.

Massive Pulmonary Emboli and CT Pulmonary Angiography

Background: Massive pulmonary embolism (PE) is a devastating form of PE which usually results in acute right ventricular failure and death within 1–2 h. Objectives: To retrospectively assess pulmonary vascular, cardiac, pleural, and parenchymal findings on CT pulmonary angiography (CTPA) in patients with a diagnosis of massive PE (systolic blood pressure <90 mm Hg, syncope and/or shock). Methods: In 33 consecutive patients with proven massive PE, hemodynamic severity was assessed by the extent of right ventricular dysfunction (RVD); diameter of the main pulmonary artery; the shape of the interventricular septum; and the extent of obstruction to the pulmonary arterial circulation (CT obstruction index). Results: Central pulmonary arteries were embolized in all patients. RVD was detected in all patients (94% of them had severe RVD); the diameter of the main pulmonary artery was wider than normal in 76% of the patients; the shape of the interventricular septum was abnormal in all patients, and the CT obstruction index was higher than or equal to 50% in 85% of the patients. Wedge-shaped pleural-based consolidation was the most common parenchymal abnormality (36%). Pleural effusions were seen in 26 patients (79%). Twenty-eight patients were alive, and only the use of thrombolytic therapy was found to be statistically significant. Conclusions: In patients with acute massive PE, embolization of the central pulmonary arteries, RVD and displacement of the interventricular septum are commonly seen with CTPA. A CT obstruction index of >50% is commonly observed in massive PE. There was no association between CTPA findings and survival.

Pulmonary Embolism as a Cause of Death in Patients With Heart Disease: An Autopsy Study

To establish the prevalence of pulmonary embolism (PE) in autopsy material at a tertiary cardiac referral center and its importance as a cause of death in patients with heart disease (HD).Case series.National Heart Institute, Mexico City.One thousand thirty-two patients who died at our institution from 1985 to 1994 in whom an autopsy study was performed.Of the 1,032 autopsies reviewed, 231 cases (24.4%) of PE were found; 100 of these patients had a diagnosis of massive PE. Massive PE (obstruction of either of the main pulmonary arteries or more than two lobar arteries) was found to be the third cause of death in this HD population. By age-group distribution, the global prevalence of massive events was higher in patients < 10 years old. Clinical suspicion (premortem) was raised in only 18% of the cases.PE was a frequent cause of morbidity and mortality in patients with HD who underwent autopsies. The incidence of massive PE was high in children.

“Thrombus in transit” – the role of echocardiography in the diagnosis of massive pulmonary embolism and a review of the literature

The diagnosis of acute pulmonary embolus is often difficult.We present a case history where bedside transthoracic echocardiography provided a rapid and convenient aid to diagnosis by demonstrating a venous “thrombosis in transit” as a spiral shaped mass in the right atrium prolapsing into the right ventricle.We also review the management and outcome in recent, similar cases. Overall mortality is 33% for pulmonary embolus and associated thrombus in transit.Transthoracic echocardiography may be a useful tool in the diagnosis of pulmonary embolus. The presence of thrombus in the right heart is a rare finding. The outcome in these patients is determined by the clinical presentation rather than by the identification of thrombus.

RAPID DIAGNOSIS OF MASSIVE PULMONARY EMBOLISM IN A DISTRICT GENERAL HOSPITAL

SUMMARYEffective treatment of massive pulmonary embolism is more likely if diagnostic tests are rapidly available, including during out‐of‐hours. An agreed protocol was implemented in November 1997, which allowed initiation of thrombolysis by junior doctors within an hour of clinical suspicion of the diagnosis of massive pulmonary embolism in six patients in the subsequent year. A similar approach could be considered by other acute hospitals. (Int J Clin Pract 2000; 54(3): 144‐146)

Diagnosis and Treatment of Shock Due to Massive Pulmonary Embolism: Approach With Transesophageal Echocardiography and Intrapulmonary Thrombolysis

To evaluate the diagnostic value of transesophageal echocardiography (TEE) as an initial diagnostic tool in shocked patients. The second objective was to study therapeutic impact of intrapulmonary thrombolysis in patients with diagnosed massive pulmonary embolism. Prospective observational study. Medical ICU in 800-bed general hospital. Twenty-four consecutive patients with unexplained shock and distended jugular veins. In 18 patients, right ventricular dilatation with global or segmental hypokinesis was documented. In addition, central pulmonary thromboemboli (12 patients), reduced contrast flow in right pulmonary artery (one patient), and right ventricular free wall akinesis (one patient) were found. No additional echocardiographic findings were apparent in four patients. According to pulmonary scintigraphy or autopsy, sensitivity of TEE for diagnosis of massive pulmonary embolism (MPE) in patients with right ventricular dilatation was 92% and specificity was 100%. In patients without right ventricular dilatation, left ventricular dysfunction (four patients) or cardiac tamponade (two patients) was confirmed. Intrapulmonary thrombolysis was evaluated in 11 of 13 patients with MPE. Two patients died prior to attempted thrombolysis. Three patients received streptokinase and eight received urokinase. Twenty-four hours after beginning of treatment, total pulmonary resistance index significantly decreased for 59% and mean pulmonary artery pressure for 31%. Cardiac index increased for 74%. Nine of 11 patients receiving thrombolysis survived to hospital discharge. Bedside TEE is a valuable tool for diagnosis of MPE. It enables immediate intrapulmonary thrombolysis, which seems to be an effective therapeutic alternative in our group of patients with obstructive shock.

Transesophageal echocardiographic diagnosis of massive pulmonary embolism during cardiopulmonary resuscitation

Transesophageal echocardiographic diagnosis of massive pulmonary embolism during cardiopulmonary resuscitation