PE with Bleeding

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed both her Emergency Medicine training and Clinician Educator Diploma at McMaster University.

Why it Matters

Many simulation cases that deal with pulmonary embolism seem to focus on the decision to administer thrombolytics (usually upon a patient’s arrest). This case is different. While the team must administer thrombolytics to a patient with known pulmonary embolism, the catch is that they must then also recognize shock as a result of intra-abdominal bleeding. As a result, the case highlights the following:

  • The dose of thrombolytics to be used in the context of cardiac arrest
  • The importance of an approach to undifferentiated shock after ROSC. (It’s not all cardiogenic!)
  • That bleeding is a complication of thrombolysis. This is drilled into our brains as the major complication, but somehow it is diagnostically challenging to recognize.

Clinical Vignette

You are called urgently to the bedside of a patient who is in the Emergency Department awaiting medicine consultation. Your colleague saw her earlier. She is 63 years old and has a CT-confirmed pulmonary embolism. She had presented with shortness of breath on exertion in the context of a recent hysterectomy 4 weeks ago. She has been stable in the ED until she got up to go to the bathroom and suddenly developed severe shortness of breath.

Case Summary

A 63-year-old female is in the Emergency Department awaiting internal medicine consultation for a diagnosed pulmonary embolism. She suddenly becomes very short of breath while walking to the bathroom and the team is called to assess. The patent will then arrest, necessitating thrombolysis. After ROSC, she will stabilize briefly but then develop increasing vasopressor requirements. The team will need to work through the shock differential diagnosis and recognize free fluid in the abdomen as a complication of thrombolysis requiring surgical consultation and transfusion.

Download the case here: PE with Bleeding

ECG for the case found here:

Massive PE ECG

(ECG source: https://lifeinthefastlane.com/ecg-library/pulmonary-embolism/)

Initial CXR for the case found here:

normal female CXR radiopedia

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Post-intubation CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Pericardial ultrasound for the case found here:

Normal lung ultrasound for the case found here:

Abdominal free fluid ultrasound for the case found here:

RUQ FF

(All ultrasound images are courtesy of McMaster PoCUS Subspecialty Training Program.)

Massive Pulmonary Embolism

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

The management of massive pulmonary embolism is one that requires rapid action and decisive decision-making, often based on less information than one would like. This case highlights several key features of the management of a massive PE, including:

  • The importance of recognizing the signs of PE and using basic bedside investigations to aid in diagnosis when a patient is too unstable for confirmatory CT
  • The need to maintain quality ACLS care when a patient arrests, regardless of arrest etiology
  • The use of thrombolytics during cardiac arrest to treat a suspected pulmonary embolism

Clinical Vignette

A 46 year old male presents to the ED complaining of shortness of breath and pleuritic chest pain. He broke his ankle a week ago and has been in a cast since. He was just discharged home after operative repair 2 days ago.

Case Summary

A 46 year old male with a cast on his left leg from a bad ankle fracture presents to the ED complaining of pleuritic chest pain and shortness of breath. The team will take a history and start workup when the patient will suddenly state he’s “not feeling well” and then arrest. The team will perform ACLS consistent with the PEA algorithm and should consider IV thrombolytics. If IV thrombolytics are administered, the patient will have ROSC.

Download the case here: Pulmonary Embolism

ECG for the case found here:

ecg-massive-pte

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/ECG-Massive-PTE.jpg)

Post-intubation CXR for the case found here:

Post-Intubation

Post Intubation

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Cardiac U/S showing right heart strain found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

Cardiac U/S showing cardiac standstill found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)