Question of the Week # 79

79) A 38-year old female on birth control pills, has suddenly become extremely short of breath.  Someone has seen her collapse and called 911.  She was diaphoretic and complained of severe chest pain before she collapsed.  She is now in the ER/ED and you have been asked to evaluate her. Her old records show that she is a cocaine abuser and was admitted for subarachnoid hemorrhage 6 weeks ago from which she completely recovered. Clinical findings revealed Vitals : B.P 65/ palpable, R.R 45. Pulse 140, Tm: 99.2 F. Chest exam revealed decreased breath sounds in right lower lobe and distant heart sounds. Pulse oximetry revealed 88%. EKG showed sinus tachycardia with a q wave and T wave inversion in lead III. 2D echo showed global hypokinesis of the Right Ventricle and  pulmonary hypertension. You started her on Intravenos fluids and her blood pressure has slightly improved to 66/30. Your next step in management ?

       A) Transfer to cath lab and notify the interventional cardiologist stat

       B) Intra aortic balloon counterpulsation

       C) Thrombolytic therapy

       D) Surgical Embolectomy and Inferior vena cava filter

       E) Obtain cardiothoracic surgery consult for subxiphoid window

9 Responses

  1. D

  2. D.
    Absolut c/i to tpa:

    History of hemorrhagic stroke
    Active intracranial neoplasm
    Recent (< 2 months) intracranial surgery or trauma
    Active or recent internal bleeding in prior 6 months: this patient had SAH which is an internal bleeding, 6 weeks back.
    This pt. had SAH not a hemorrhagic stroke.

  3. 38 yo on OCP, suden onset of SOB and Chest pain Hx of SAHH 6 weeks ago decrease BP, Tachypnea, Decrease Breath sounsds in R lower lobe R Ventricular failure (unable to pump blood infarcted lung area– Dx PE Tx Embolectomy

  4. interesting question! I wonder what u do if not at a major referral centre, in reality most hospitals will not have emergent embolectomy, do we let her die or gamble for tpa? 😉

  5. the answer is emergency embolectomy, SAH in the last 6 months, and she has a massive PE as she has pulmonary hypertension, without emergency embolectomy she will die, so interesting point whether to rist TPA, but you have a high rish of another SAH and 2nd SAH has more than 50% mortality, best to get a helicopter quick to a major center

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