A 72-year-old male presented to our ED with a chief complaint of pre-syncope.

 

Initial vitals: HR 86, BP 83/59, SpO2 93% on RA

 

The patient reported having multiple episodes of pre-syncope throughout the day.  He was feeling better and had no complaints by the time he had arrived to the ED. He specifically denied chest pain, SOB, nausea, vomiting, diarrhea, blood in his stools, hematemesis, anorexia, palpitations, or abdominal pain.

 

Repeat vitals signs revealed persistently low blood pressure.

 

When someone presents with hypotension, we tend to do a “whole body ultrasound.” We look at the heart, lungs, and IVC so that we can know more about fluid status and cardiac function. We also look at the aorta to rule out an AAA and look for free fluid in the abdomen.   This evaluation takes seconds to minutes.

 

It was difficult to obtain the four standard cardiac views in this gentleman, however the subcostal view is shown below.

 

 

In this view, the patient has grossly normal left ventricular cardiac function, but the right atrium and ventricle look abnormal. You can see echogenic material wirling around. This was investigated more and you can appreciate what is going on in this view of the IVC entering the right atrium.

 

 

There is something swirling between the right atrium and the IVC, which was interpreted as a blood clot in the right atrium indicating that this patient’s hypotension was from a pulmonary embolism. The patient’s legs were also imaged with two point compression.

 

 

From these images you can see that there was also echogenic clot (DVTs) in the right and left popliteal veins.  Normal compression is seen in the right and left femoral veins. The cause of this patient’s hypotension was unequivocally determined within minutes of presentation to the ED.

 

After 2 liters of IVF, the patient’s BP improved  to 105/69 and now there was a dilemma. Should the patient receive treatment with systemic anticoagulation alone or systemic anticoagulation + thrombolytics or an embolectomy?

 

The American College of Chest Physicians current recommendations for the treatment of acute PE

  • Those with hypotension (SBP<90) should be administered thrombolytics if not at high risk for bleeding
  • Most without hypotension should not get thrombolytics, however, some at high risk of developing hypotension should be administered thrombolytics
  • In patient’s with hypotension, catheter based thrombus removal should be performed if there is a contraindication to thrombolysis, failed thrombolysis, or shock that is likely to cause death before thrombolysis can take effect
  • Surgical embolectomy is suggested as in the above circumstance if catheter based thrombus removal also fails

 

It is difficult to know which category this patient falls into. He was hypotensive, but not after IVF. He was asymptomatic although he did have evidence of a large clot burden (clot in the right atrium and ventricle and in both legs). His Troponin I was elevated to 0.322 and his BNP was elevated to 2819. The standard dose of tPA for PE is 100 mg over 2 hours, however, there is some evidence that in moderate PEs a lower does is safe and efficacious at lowering pulmonary artery pressure in the long term.

 

The patient was ultimately started on heparin and then received an intravenous bolus of tPA in the ED of 50 mg.  He was admitted to the MICU. He did well and was discharged from the hospital on hospital day 7 without complication.  A repeat formal TTE on hospital day 3 showed resolution of the clot that was seen in the right side of the heart.

 

How would you have managed this patient?

 

 

References

  1. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guideline. Chest 2012;141:e419s
  2. Sharifi M, Bay C, Skrocki L, et al. Moderate Pulmonary Embolism Treated with Thrombolysis (from the “MOPETT” trial). American Journal of Cardiology 2013;111(2):273-277
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