Transcript 2007_06_14-DaSilva-Massive_PE

Interesting Case
Stefan Da Silva
CCFP-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
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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 1415hrs
 Pt 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
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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
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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
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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 halflife = 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 patient
 Passed away May 3/07