Dr. Luis A Aguilar Montalvan (PGY3) and Dr. Susan Albow
Our patient is a middle-aged female HLD, DM, high-risk MSS, KRAS- WT stage IIIc (pT4aN2a) colon (ascending) cancer, s/p lap R hemi-colectomy on 11/25/2020, followed by completion of 7 cycles of adjuvant XELOX on 6/14/21, with recurrent metastatic disease to ovaries s/p BSO on 6/7/23, s/p C1 of adjuvant dose-reduced XELOX on 7/12/23.
Vitals: BP 109/59, HR 134, RR 25, 97% RA, 97.5 F
Physical Exam: Our patient was in severe respiratory distress with increased work of breathing and using accessory muscles, but still able to communicate in semi-full sentences, clear lungs to auscultation bilaterally, no signs of LE DVT, tachycardic with regular rate, no murmur, gallops or rubs, AOx3, pupils normal size, equal, round, reactive to light.
The patient was brought in via EMS with CC: “Respiratory distress. O2 sat 80% on RA per EMS. On NRB, O2 sat 97%. Denies chest pain. + Labored breathing.” The triage Nurse called for a STAT BiPAP. RN notified me within 2 minutes of arrival to our ED, and told me it was an “Asthma Exacerbation.” I was the first to arrive, when I asked EMS, it was a BLS crew, they told me that they heard b/l wheezing. The patient was in obvious respiratory distress, I asked her if she had a history of Asthma/COPD, and she said no - First red flag for me. I listened to her lungs and they were normal - second red flag. I asked her what her PMH was, she told me she was in remission from metastatic colon cancer - the third red flag. I was still the only person at the bedside, I grabbed the Phase Array US probe to confirm my suspicion, images were impressive for right heart strain (Figures 1 and 2) and dilated IVC (Figure 3).
Figure 1: Apical Four-chamber view of the heart notable for McConnells sign and septal bowing
Figure 2: Parasternal short view of the heart notable for septal bowing
Figure 3: IVC view notable for dilated IVC with minimal respiratory variation
I requested an ECG (Figure 4), cardiac monitor, labs, called off BiPAP, told the team strictly to not put any NIPPV on this patient, and notified my attending.
Figure 4: ECG notable for S1Q3T3, concerning for pulmonary embolism
The initial plan was to take the patient for a STAT PE study. But, we felt uncomfortable with that plan because we had already confirmed signs of massive PE, the patient could decompensate at any time, especially on transport to CT. She needed immediate intervention with thrombolytic or at least AC therapy.
While we prepared to transport her to CT, the repeat blood pressure dropped to 80/45. I called off the transport plan and initiated 1 L of bolus normal saline, systolic BP slightly improved and remained at 90s. The patient remained awake and alert. I ordered immediate heparin bolus and infusion and also ordered tPA to be drawn.
CCM requested immediate intubation for this patient, but I disagreed and pushed back. She remained borderline hypotensive, but was still mentating well, still conversing with us, appeared somewhat improved in her respiratory distress despite remaining tachypneic to 30s, and responded to oxygen therapy, so I thought that we still had time to address the obstructive shock first. Her blood pressure dropped once more.
This drop was enough to push us to give the tPA. We gave it in aliquots of 50 mg, I think within 10-15 mins of each other. There was no real response to her hemodynamics, her BP dropped again so we had to start her on NE. We discussed intubation and planned to take her to the ICU for monitoring and reassess for thrombectomy.
She remained AOX3 during this process, we spoke with her about the risks and benefits, and the need for intubation. Her mother was also at the bedside, they both spoke and made a decision together. Right before we started the RSI meds, the patient told her mom, “I’ll be okay, but no matter what happens, remember I love you.” She said it very matter of fact, she did not appear afraid and was joking around at some point. This scared me more because I was going to intubate her and that could kill her. But it also gave me ownership of her health because she trusted us with her life.
She ultimately did well, received a thrombectomy, and was discharged 12 days later, doing well.
Luis' Takeaways
tPA Management of the hemodynamically unstable patient with suspected pulmonary embolism:
Alteplase Dosing
Cardiac Arrest, pulmonary embolism suspected: 50mg IV rapid push over 2 minutes
May repeat 50mg dose after 15 minutes if there is no ROSC
Imminent Cardiac Arrest from suspected pulmonary embolism: 20mg IV bolus over 2 minutes, followed by 80mg continuous IV infusion over 2 hours
Alternatively, could do 0.6mg/kg IV (Max 50mg) over 15 minutes
Massive Pulmonary Embolism, hemodynamically unstable: 100mg continuous IV infusion over 2 hours
May give 10% of 100mg dose as an IV bolus over 1 minute
Alternatively, low dose tPA (for high risk bleeding or elderly patients), may administer 50mg continuous IV infusion over 2 hours
Submassive Pulmonary Embolism: 100mg IV infusion over 2 hours
May give 10% of dose as an IV bolus over 1 minute
Alternatively, low dose tPA (for high risk bleeding or elderly patients), may administer 0.6mg/kg IV infusion over 2 hours
Also, separate from the medical management - the fear that awoke in me from this case is that we are constantly placed in situations with a high likelihood of severe adverse events, and all it takes to harm someone’s life is an inexperienced clinician, a burned-out clinician, a clinician having an off day, or a clinician with divided attention anchoring on what initially appears like a common presentation to a common illness, and disengage their active thinking.
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