(P58) Bedside Ultrasound Guidance of Thrombolysis in a Male Patient with Pulmonary Embolism and Cardiac Arrest in the Emergency Department

Chief Complaint : We present the case of a 66-year-old male patient brought to the ED due to out-of-hospital cardiac arrest after complaining of sudden-onset dizziness at home.

History of Present Illness : A 66-year-old male with no past medical history of systemic illness was brought to the ED by EMS personnel in cardiac arrest. The patient's wife called EMS after the patient had a syncopal episode at home. Upon EMS arrival to the patient's home, the patient was awake complaining only of dizziness. After the patient was placed in a stretcher by EMS personnel, the patient became unresponsive and was found to be pulseless. Advanced Cardiac Life Support Protocol was initiated by EMS personnel. The patient underwent resuscitative efforts for 25 minutes prior to arrival to the ED. The patient arrived to the ED in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. Resuscitative measures following ACLS guidelines were continued by the emergency physicians. The patient underwent endotracheal intubation in the ED.

Pertinent Physical Exam: A limited physical examination revealed jugular venous distension and right lower extremity edema. Cardiac POCUS performed during pulse checks demonstrated an enlarged right ventricle. POCUS of the patient's right lower extremity was also performed during ongoing CPR, revealing an occlusive DVT extending from the common femoral-saphenous vein junction to the femoral vein. POCUS findings were considered by the Emergency Physicians to be indicative of a massive pulmonary embolism.

Pertinent Laboratory Data: Initial laboratory studies revealed a troponin level within normal limits. Computed Tomography Angiogram (CTA) of the chest performed after ROSC confirmed the presence of bilateral pulmonary emboli with evidence of right heart strain.

Case Discussion: POCUS findings were considered by the Emergency Physicians to be indicative of a massive pulmonary embolism. Guided by POCUS findings, an initial bolus of 50 mg of intravenous (IV) alteplase was administered as CPR continued. Approximately 12 minutes after the administration of alteplase and continuation of CPR, return of spontaenous circulation (ROSC) was achieved. A second dose of 50 mg IV alteplase was then administered. Computed tomography angiogram (CTA) of the chest performed after ROSC confirmed the presence of bilateral pulmonary emboli with evidence of right heart strain. The management of cardiac arrest is a cornerstone in the practice of an Emergency Physician. Recognizing the possible causes for a patient's cardiac arrest is essential in order to improve the likelihood of achieving ROSC with a favorable neurologic outcome for the patient. Pulmonary embolism is one of the entities likely to cause cardiac arrest. In a patient brought to the ED in cardiac arrest, assessing the patient's risk for a pulmonary embolism may be difficult as the patient's history and physical exam findings are often limited. Thus, making a clinical diagnosis under these circumstances presents a tremendous challenge. POCUS is an invaluable tool which helps resuscitative efforts in a patient in cardiac arrest. Whereas performing cardiac POCUS may be difficult during chest compression cycles, compression pauses of a maximum of 10 seconds may be sufficient to obtain adequate sonographic views of the heart. Cardiac POCUS performed by the Emergency Physicians in this case demonstrated findings suggestive of a PE with severe right heart strain and an occlusive right lower extremity DVT, increasing the likelihood of a PE being present. The findings on POCUS led to the expeditious recognition and medical management of the venous thromboembolism. The patient had made a complete neurologic recovery at the time of discharge from the hospital.

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