A 54-year-old man comes to the emergency department after an episode of syncope. While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode. He regained consciousness within a minute but continues to have chest "heaviness" and shortness of breath. Two days ago, the patient returned home from an extended car trip. He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy. He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs. Temperature is 38.3 C (100.9 F), blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2. Laboratory results are as follows:
ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes. CT angiography reveals filling defects in the bilateral main pulmonary arteries. Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.
The patient develops progressive hypoxemia requiring 100% supplemental oxygen via a nonrebreather mask, but even with treatment his respiratory distress worsens and he becomes progressively confused and lethargic. Endotracheal intubation is performed and mechanical ventilation is initiated. Intravenous norepinephrine infusion is started due to persistent hypotension. Bedside echocardiography reveals right ventricular dilation and hypokinesis, but left ventricular contractility is normal. Which of the following is the best next step in management of this patient?

Question

A 54-year-old man comes to the emergency department after an episode of syncope.  While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode.  He regained consciousness within a minute but continues to have chest "heaviness" and shortness of breath.  Two days ago, the patient returned home from an extended car trip.  He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy.  He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air.  The lungs are clear to auscultation.  Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2.  Laboratory results are as follows:
 ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes.  CT angiography reveals filling defects in the bilateral main pulmonary arteries.  Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.
The patient develops progressive hypoxemia requiring 100% supplemental oxygen via a nonrebreather mask, but even with treatment his respiratory distress worsens and he becomes progressively confused and lethargic.  Endotracheal intubation is performed and mechanical ventilation is initiated.  Intravenous norepinephrine infusion is started due to persistent hypotension.  Bedside echocardiography reveals right ventricular dilation and hypokinesis, but left ventricular contractility is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c08b_2eb0_8f63_4d67bddd482c_MD0005_00 This patient who has a pulmonary embolism (PE) associated with right ventricular dysfunction and hemodynamic instability requiring vasopressor support should receive immediate thrombolytic therapy. In patients with PE, hemodynamic instability is the most important indication for thrombolysis, which can be administered via either systemic infusion or catheter-directed therapy. Other relative indications for thrombolysis include severe right ventricular dysfunction, large clot burden, and evidence of free, right-sided cardiac thrombus. Contraindications include intracranial neoplasm or prior hemorrhage, cerebrovascular abnormalities, active bleeding, and recent cranial trauma. In patients who cannot undergo thrombolytic therapy, surgical or catheter-directed embolectomy should be considered. (Choice B) Inotropic support (eg, milrinone) may be warranted in patients with acutely decompensated heart failure or right heart failure due to myocardial ischemia, but it would not treat this patient's underlying problem (pulmonary arterial thrombotic obstruction) and is not the next step in management. (Choice C) Although most patients with PE should be started on anticoagulation (eg, heparin), those with hemodynamic instability should have anticoagulation held until after thrombolytic therapy to minimize bleeding risk. (Choice D) Low tidal volume ventilation is important for preventing the risk of barotrauma in acute respiratory distress syndrome, which is due to diffuse inflammatory changes in the lungs and does not typically cause right ventricular dilation and hypokinesis. Patients with hemodynamic instability due to PE require emergent thrombolysis. (Choice E) The most common reasons for the placement of an inferior vena cava filter include the inability to tolerate anticoagulation or breakthrough PE on anticoagulation. Although filters may be placed prophylactically in patients who are unlikely to tolerate another PE, they are not first-line management. Educational objective: Hemodynamic instability is the most important indication for thrombolysis in patients with pulmonary embolism. Other relative indications for thrombolysis include severe right ventricular dysfunction, large clot burden, and evidence of free, right-sided cardiac thrombus. References: Advanced treatment strategies for acute pulmonary embolism, including thrombolysis and embolectomy. (http://www.ncbi.nlm.nih.gov/pubmed/19630826) Developments in the management and treatment of pulmonary embolism. (http://www.ncbi.nlm.nih.gov/pubmed/26324810)

A 54-Year-Old Man Comes to the Emergency Department After an Episode