two in two days…

I have recently prepared a lecture on a current, yet still controversial topic for work following exposure to these two interesting cases. Here are the cases & their discussion as well as the slide-show attached… 

case one.

a 74 year old male presents to ED following a syncopal episode at home. He apparently collapsed without warning whilst taking the rubbish outside.

With the paramedics, he is alert & oriented but has a pulse of 120 per min and a systolic blood pressure of 70mmHg. His prehospital ECG demonstrates a right bundle branch block that resolves prior to ED arrival.

He arrives to ED in extremis. He is agitated, hypoxic [SaO2 92% on 15L NRB, RR 32, clear chest] & shocked [P 124, BP 72/50, cold & mottled]. Whilst his GCS is 13, he has no focal neurological signs. His blood glucose & temperature are normal.

Before you continue. Pause to consider the potential diagnoses. How are you going to differentiate these further ??

[DDET Case 1 – initial RESULTS…]

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[DDET Case 1 – PROGRESS…]

Initial resuscitation.

• High-flow oxygen via non-rebreather mask
• 2x large-bore IV-access
• Empiric fluid bolus

Differential diagnoses.

• Undifferentiated shock [cardiogenic vs septic vs obstructive…]
  • ?AMI
  • ?AAA
  • ?Aortic dissection
  • ?Haemorrhage
  • ??sepsis, others….

You take your ultrasound to the bedside…

httpv://youtu.be/P2bfuvh5v4E

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[DDET Case 1 – DIAGNOSIS…]

These findings on the RUSH exam allowed us to make the provisional diagnosis of massive pulmonary embolism with obstructive shock !

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[DDET Case 1 – CONCLUSION…]

Unfortunately, soon after the diagnosis is made the patient deteriorates and has a PEA arrest. The decision is made to threat with empiric thrombolysis with alteplase.

There is a protracted period of resuscitation with periods of spontaneous circulation interspersed  with short bursts of CPR. Despite an ongoing, escalating adrenaline requirement he was safely [eventually] transferred to Intensive Care.

Unfortunately, he has a further PEA arrest and subsequently asystole some 7 hours after arriving to ED and could not be resuscitated.

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[DDET The DISCUSSION !!]

THROMBOLYSIS FOR PULMONARY EMBOLISM

Here are the slides from my presentation looking at the evidence & potential roles for thrombolysis for pulmonary embolism.

[slideshare id=33205118&doc=thrombolyticsforpulmonaryembolism-140406223428-phpapp02] 

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[DDET Case TWO…]

case two – precisely 24 hours later….

a 47 year old female is bought to ED following a pre-hospital notification regarding her ‘life-threatening asthma’.

She was found by paramedics to have significant respiratory distress & profound hypoxia, so administered intramuscular adrenaline [500mcg x2] plus continuous salbutamol whilst transporting her to ED.

Upon arrival she is alert with a patent airway, but profound tachypnoea & hypoxia [RR 44, SaO2 92% 15L NRB]. Surprisingly she has a clear chest with good air-entry. There are no wheezes or crackles. She is tachycardic but normotensive [P 124/min, BP 118/70], with warm peripheries.

You cannot help but notice she has a “Cam boot” on her right foot. She sustained an undisplaced Weber B fracture 3 weeks earlier, which has been managed conservatively.

Again, pause to consider the potential diagnoses. How are you going to differentiate these further ??

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[DDET Case 2 – initial RESULTS…]

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[DDET Case 2 – PROGRESS…]

Initial resuscitation.

• BiPAP initiated for oxygen requirement & work of breathing.
• IV access & empiric fluid bolus
• Heparin bolus + infusion based on presence of cam-boot & potential for DVT/PE
• Empiric IV ABx given; atypical presentation.

Differential diagnoses.

• Pulmonary embolism
• ?Asthma – less & less likely…
• ?Infectious
• ?Metabolic

You take your ultrasound to the bedside…

httpv://youtu.be/Re-RU6CQ-AY

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[DDET Case 2 – DIAGNOSIS…]

Our concerns…

With these findings, our predominate concern was for submassive pulmonary embolism.

It is acknowledged that further investigation (ie. CTPA) was impossible without intubation & mechanical ventilation due to profound oxygen requirement and inability to lay-flat.

A decision is made for RSI, which takes place without issue.

Here is her CTPA…

httpv://youtu.be/GZQUqCpzxeg

Now ask yourself….
Are you going to use thrombolysis on this patient ?!?!

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[DDET Case 2 – CONCLUSION…]

It is decided given her oxygen requirement, age and clot-burden to proceed to thrombolysis. She receives 100mg of alteplase over two hours.

The following morning she is extubated without issue [ie. normal gas-exchange] & is discharged home on Day 5 !!

This is her discharge ECHO…

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[DDET FINAL SUMMARY & CONCLUSION]

• Consider massive & submassive PE as a cause for undifferentiated shock.
• Have a low threshold to investigate these patients yourself with a bedside ECHO [ie. specifically, RUSH exam, extension of BLUE protocol].
  • Includes undifferentiated shock or unexplained dyspnoea/hypoxia.
• ECHO specifics to examine include:
  • RV size [esp. RV:LV ratio]
  • RV contractility ?hypokinesis.
  • Paradoxical septal motion [ie. flattening or leftward bowing]
  • McConnell’s sign – right ventricular free wall hypokinesis with apical sparing.
  • Tricuspid regurgitation.
• Consider thrombolysis in:
  • Massive PE
  • Presumed massive PE with PEA arrest/shock
  • Submassive PE:
    • Profound RV dysfunction [abnormal ECHO + positive troponin]
    • Severe hypoxaemia/oxygen requirement
    • Age < 75
• Consider contraindications carefully

• Remember there are other alternatives:
  • Interventional radiology
  • Cardiothoracic surgery

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[DDET The full slideshow…]

[slideshare id=33204988&doc=2in2days-140406222753-phpapp01]

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[DDET References.]

Literature.

• Goldhaber SZ, Visani L, De Rosa M, et al. for ICOPER. Acute pulmonary embolism; clinical outcomes in the International Cooperative Pulmonary Embolism Registry. Lancet 1999;353:1386-1389
• Grifoni, S., Vanni, S., Magazzini, S., Olivotto, I., Conti, A., Zanobetti, M., et al. (2006). Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Archives of internal medicine, 166(19), 2151–2156. doi:10.1001/archinte.166.19.2151
• Kline, J. A. (2009). Prospective Evaluation of Right Ventricular Function and Functional Status 6 Months After Acute Submassive Pulmonary Embolism. Chest, 136(5), 1202. doi:10.1378/chest.08-2988
• Frémont, B. (2008). Prognostic Value of Echocardiographic Right/Left Ventricular End-Diastolic Diameter Ratio in Patients With Acute Pulmonary Embolism *. Chest, 133(2), 358. doi:10.1378/chest.07-1231
• Böttiger, B. W., et al. (2008). Thrombolysis during resuscitation for out-of-hospital cardiac arrest. The New England journal of medicine, 359(25), 2651–2662.
• British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. (2003, June). British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax.
• Jaff, M. R., Mcmurtry, M. S., Archer, S. L., Cushman, M., Goldenberg, N., Goldhaber, S. Z., et al. (2011). Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation, 123(16), 1788–1830. doi:10.1161/CIR.0b013e318214914f
• Konstantinides, S., et al. Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. (2002). Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. The New England journal of medicine, 347(15), 1143–1150.
• MD, M. S., PhD, C. B., DO, L. S., MD, F. R., DMD, M. M., & Investigators, M. (2013). Moderate Pulmonary Embolism Treated With Thrombolysis (from the “MOPETT“” Trial). The American Journal of Cardiology, 111(2), 273–277.
• Steering Committee. (2012). Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial. American Heart Journal, 163(1), 33–38.e1.
• Sharifi, M., Bay, C., Schwartz, F., & Skrocki, L. (2014). Safe-dose thrombolysis plus rivaroxaban for moderate and severe pulmonary embolism: drip, drug, and discharge. Clinical cardiology, 37(2), 78–82. doi:10.1002/clc.22216
• PEITHO RESULTS (slideshow) via ClinicTrialResults.org
• MD, S. D., RN, P. M., BA, L. R., RDMS, M. L. M., MPH, J. R.-S., MPH, S. B., et al. (2014). Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism. Annals of Emergency Medicine, 63(1), 16–24. doi:10.1016/j.annemergmed.2013.08.016

Social Media covering Thrombolysis for Pulmonary Embolism.

• LITFL – Thrombolysis for submassive pulmonary embolism
• RAGE Podcast – Session two
• EMNerd.com – The Adventure of the Greek Interpreter
• EMCrit.org;
  • Podcast #51 – Fibrinolysis in Pulmonary Embolism
  • EMCrit Wee – MOPETT Trial
• REBEL EM – Diagnosis of Right Ventricular Strain with Transthoracic Echocardiography

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