Wed17November0747PM 3

A 38-year-old lady presents to the acute medical unit with a sharp pleuritic chest pain of sudden onset two days previously. She is normally fit and well with no previous history or family history of note.

On examination her respiratory rate is raised at 22 breaths per minute. Her arterial blood gas reveals the following:

FiO2 0.35

pH 7.44

pO2 9.8 kPa

pCO2 3.9 kPa

HCO3 24

Whilst awaiting a chest x ray her blood pressure drops to 66/30 mmHg. She becomes cyanosed but still conscious and complains of increasing heaviness on her chest.

What is the next best management step?

(Please select 1 option)

Immediate thrombolysis with streptokinase over two hours

Immediate initiation of IV heparin

Urgent discussion for CTPA with outreach/ICU assistance

Low molecular weight heparin subcutaneous with urgent bedside echocardiography

50 mg alteplase bolus Correct

Explanation

This case is strongly suggestive of a massive pulmonary embolism. The only difficulty here is that the diagnosis has not yet been confirmed by CTPA. However, trying to transfer the patient to CTPA whilst she is unstable is risky given the high mortality of massive PE.

The correct management of a clinically suspected life threatening PE is alteplase 50 mg for immediate thrombolysis. If the blood pressure is stable but there are signs of right heart strain (for example, S1Q3T3 on ECG, troponin rise or right ventricle dilatation/interventricular straightening on echocardiography), then it is a suspected submassive PE.

In this situation thrombolysis is not recommended, although individual cases should be discussed with respiratory specialists.

Reference:

British Thoracic Society. Pulmonary Embolism.

Answer Statistics

1

10%

2

7%

3

12%

4

22%

5

51%

Times answered: 294