Interesting Case

Stefan Da SilvaCCFP-EM

June 14th 2007

80 yr old female presents to PLC ER on April 1st 2007.

Chief Complaint of increasing SOBOE for 3 – 4 days.

Called EMS after acute onset of chest heaviness, SOB and diaphoresis at 1030hrs while attempting to put on coat.

No previous hx of similar. Symptoms lasted 15 – 30 minutes and were

relieved by O2 and nitro given by EMS. No radiation of pain. No recent travel or immobilization. No recent cough or URTI symptoms. No DVT risk factors Presently painfree in ED

Past Medical Hx– Hyperthyroid– Hypertension

Cardiac Risk Factors– Non-smoker– HTN– ? Hyperlipidemia– No previous MI’s – No diabetes– Brother had bypass surgery at 60 yrs old

Medications– Avalide– Lasix – Synthroid

Examination at 1153hrs (pt in no apparent distress)– Vitals:

• Initially: 36.6, 112 HR, 28RR, 109/65, 88% RA• At time of examination: 95 HR 125/70, 18RR, 96% with 3

liters– Cardiopulmonary Exam

• Normal heart sounds• Increased JVP• Bilateral lower leg edema• Creps to bilateral bases• No calf tenderness

Labs– Hgb = 146– Plts = 223– WBC = 12.6– Electrolytes normal– Creatinine = 134– TnT = < 0.03 (sent by nursing)– D-Dimer = 4.76

1207 hrs

Resident told to step out of department for “pad thai” after setting up CT PE (instructed to go by staff).

Pt hemodynamically stable upon departure.Returns with hot lunch and told by first

nurse that his patient is “coding”.Rushes in the find his staff in process of

intubating patient…..

According to PCA pt just finished bowel movement and was transferring back to bed from commode when she collapsed.

Time of collapse approx 1415hrsPt pulseless and CPR started.Pt intubated and the resuscitation begins….

1408hrs

Drugs Given– Atropine 1 mg for slow PEA – 1 mg epi– TNK 40mg (8000 Units) given at 1448hrs in discussion

with ICU staff on call.– Multiple doses of epi secondary to repeated episodes of

PEA and eventual epi drip placed.– Bicarb total of 4 amps given.– Amiodarone and Mg given for runs of Vtach– TNK infusion started at 1529

1449hrs

1507hrs

STAT Echo ordered– RV severe dilatation and hypertrophied free

wall– Systolic flattening of septum consistent with

RV pressure overload– LV small, underfilled, hyperdynamic

Pt went pulseless 4 times during resuscitation

Pt “coded” for almost 2 hrs– Rationale needed time for TNK to work

Transferred to ICU at 1617 on epi infusion of 4 ug/min.

At time of transfer pt had pulse of approx 80 – 90 bpm, bp 115 systolic.

What does the literature say about use of thrombolytics in PEA arrest secondary to PE?– Not too much!

Retrospective study from pharmacy database 21 pts Massive PE with shock (defined as SBP < 90 or drop of 40 mmHg in

BP from normal) Given 0.6 mg/kg of Alteplase over 15 minutes and then infusion of 90

mg over 2 hrs 5 pts died one during hospitalization from metastatic Ca, 4 died

within first 4 hrs of hospital stay and all 4 had cardiac arrest either during or immediately after thrombolysis

“Minor” hemmorhagic complications no intracranial bleeds

Retrospective Cohort Study 66 patients (36 received thrombolysis) Small study so most comparisons “not statistically

significant” and only could report “trends”

Major Bleeding complications– 25% vs 10%, P value = 0.15

• No difference in bleeding rates with CPR duration– 25% vs 25%, P = 0.99

ROSC– 67% vs 43%, P value = 0.06

Survival > 24hrs– 53% vs 23%, P value = 0.01

Survival to discharge– 19% vs 7%, P value 0.15

Overall in hospital mortality of pts with MPE = 86%

Thrombolytic therapy for pulmonary embolism: frequency of intracranial hemorrhage and associated risk factors. Daniel S. Kanter, Katriina M. Mikkola, Sanjay R. Patel, J. Anthony Parker and Samuel Z. Goldhaber.         Chest v111.n5 (May 1997): pp1241(5). 

Retrospective descriptive controlled analysis 312 patients Most common rt-PA Frequency of intracranial hemmorhage up to 14 days post lytics was

1.9 % (95% CI, 0.7 – 4.1) 2 out of the 6 hemorrhages were fatal Elderly patients and patients with elevated diastolic blood pressure

were at greater risk

Prospective study 90 pts Out-of-hospital cardiac arrest No ROSC after 15 minutes then given thrombolytic and

heparin No bleeding complications related to CPR 40 pts received lytics 68% pts receiving lytics had ROSC vs 48% 24hr survival 35% vs 22% Survival to discharge 15% vs 8%

42 yr old female – 60/30 BP, 120HR, 81% RA, cyanotic,

distressed– ECG ST elevation V1 – V3– Given 80mg TNKase hemodynamically

stable after 20 minutes– Preliminary dx of PE based on ED echo

showing normal LV function and RV free wall hypokinesis and displacement of septum

Review of cases in literature Found 22 cases up to Aug 15 2006 8 cases within Carolinas Medical Center Suggest that case reports taken together are sufficient to

comprise a Phase I study of safety and efficacy of tenecteplase to treat acute PE

Only one documented case with in-hospital arrest.

Randomized, double-blinded, multi-center placebo controlled trial

1000 patients Randomized to receive placebo or thrombolytic Primary endpoints 30 day survival rate and

hospital admission Secondary endpoints ROSC, survival to 24hrs,

survival to d/c, neurological performance

There conclusion from the literature at that time:– Use of thrombolytics in cardiac arrest secondary to PE is

supported and appears to improve survival. (Lancet study)– Thrombolysis may be beneficial in patients with massive PE and

systemic hypotension although unable to comment re: mortality benefit.

– No shock but RV dysfunction no difference in mortality but some evidence that normalization of cardiac function is faster.

– For emboli with no cardiovascular compromise thrombolysis is unadvisable.

– No single agent recommended.

TNK

Aka Tenecteplase Initial half-life = 20 –

30 minutes Terminal phase half-

life = 90 – 130 minutes

Cost = ~ $2000/pt US

What happened…. ICU

– Extubated April 5th 2007 neurologically intact but developed VAP, sepsis and subsequent respiratory failure requiring re-intubation

– Transferred to MTU April 15th 2007– HOWEVER….

Pt developed following complications:– GI bleed– Right eye hymphema– Hemmorhagic cystitis– Retrosternal hemmorhage secondary to CPR– ATN requiring dialysis

Returned to ICU April 19th for hypercarbic respiratory failure secondary to bilateral pneumonia and sepsis

Also developed bowel abscess from possible diverticulitis

Code Level II on April 25th 2007 due to continuing respiratory decompensation

April 28th 2007 increasing confusion– CT head showed subdural with uncal herniation

and midline shift

Made palliative patientPassed away May 3/07