Sat27November0556PM 13

A 50-year-old female with known breast cancer and pulmonary and cerebral metastases is admitted with a two day history of breathlessness, and a syncopal episode lasting one minute earlier that day. She has no other past medical history of note.

On examination she has a GCS of 15/15, blood pressure 112/56 mmHg, heart rate 123 bpm and respiratory rate of 20/minute. There are no signs of upper or lower limb DVT.

ECG shows sinus tachycardia with right bundle branch block. Bedside echo shows signs of right heart strain. Cardiac troponin is mildly elevated.

Arterial blood gas on air is as follows:

PO2 10.4 kPa (11.3-12.6)

PCO2 4.0 kPa (4.7-6.0)

pH 7.47 (7.35-7.45)

Bicarbonate 22 mmol/L (21-29)

CTPA showed a large pulmonary embolus straddling the bifurcation of the main pulmonary trunk.

What is the best management plan?

(Please select 1 option)

Heparin followed by early referral to tertiary centre for consideration of catheter embolectomy Correct

Subcutaneous low molecular weight heparin and close observation alone

IV unfractionated heparin and close observation alone

IVC filter insertion

Thrombolysis with tissue plasminogen activator

Explanation

Though currently haemodynamically stable, the patient has a number of adverse features that have been shown to increase 30 day mortality, namely:

CT-evidence of saddle PE

echocardiographic evidence of right heart strain, and

raised cardiac enzymes.

There is currently no evidence to support thrombolysis of sub-massive PE, and expert opinion varies.

The patient has intracerebral metastases, which is a contraindication to thrombolysis. However, given her episode of collapse and adverse features, along with central location of the PE, she may well benefit from interventional techniques, such as catheter embolectomy, rheolysis (clot dissolution) or localised thrombolysis, and her case should be discussed with a tertiary cardiothoracic centre.

Reference:

Howard LS. Thrombolytic therapy for submassive pulmonary embolus? PRO viewpoint. Thorax. 2014;69:103-105.

Answer Statistics

1

51%

2

26%

3

10%

4

3%

5

13%

Times answered: 287