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Difficulty: MediumPulmonary and Critical Care

Emergency medical responders rush a 6262-year-old male to the trauma bay for abrupt-onset dyspnea, left-sided pleuritic chest pain, and near-syncope that began two hours ago. The patient arrived yesterday from a transpacific business trip. His past medical history includes essential hypertension and hypercholesterolemia. Initial assessment reveals a blood pressure of 82/5082/50 mm Hg, a heart rate of 134134/min, and a respiratory rate of 3232/min. Pulse oximetry displays an oxygen saturation of 86%86\% despite administration of high-flow supplemental oxygen. Physical examination is notable for prominent jugular venous distention and a palpable parasternal heave. Auscultation of the lungs is unremarkable. An expedited point-of-care echocardiogram is performed, showing marked right ventricular enlargement, interventricular septal bowing into the left ventricle, and severe hypokinesis of the right ventricular free wall with relative apical sparing.

Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

  1. Administer intravenous alteplaseAnswer
  2. Initiate a norepinephrine infusionAnswer
  3. C
    Administer intravenous furosemide
  4. D
    Administer intravenous sodium bicarbonate
  5. E
    Initiate empirical intravenous vancomycin and cefepime

Answer

The correct interventions are to administer intravenous alteplase and initiate a norepinephrine infusion.
The clinical vignette describes a patient with a massive pulmonary embolism, characterized by sudden-onset dyspnea, clear lungs, right ventricular strain, and hemodynamic instability (obstructive shock). For massive pulmonary embolism, the administration of systemic thrombolytics (such as alteplase) is the standard of care to rapidly dissolve the clot, reduce pulmonary vascular resistance, and relieve right ventricular afterload. Concurrently, vasopressor support is necessary to maintain systemic blood pressure and right ventricular perfusion; a norepinephrine infusion is the preferred agent as it increases systemic vascular resistance without excessively overdistending the right ventricle.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and bedside imaging.
The patient has sudden-onset dyspnea, hypotension, jugular venous distention, clear lungs, and McConnell's sign on echocardiogram following prolonged immobilization.
These findings confirm a massive (hemodynamically unstable) pulmonary embolism causing acute right ventricular failure and obstructive shock.
2
Determine the indication for reperfusion therapy.
Select intravenous alteplase.
Systemic thrombolysis is the standard of care for massive pulmonary embolism to rapidly relieve the pulmonary artery obstruction and decrease right ventricular afterload.
3
Select the appropriate hemodynamic support.
Select norepinephrine infusion.
Norepinephrine increases systemic vascular resistance, maintaining right ventricular perfusion pressure without excessively overdistending the right ventricle, which is superior to aggressive fluid loading.

Key Concept

Management of massive pulmonary embolism requires immediate hemodynamic support with vasopressors (e.g., norepinephrine) and rapid reduction of right ventricular afterload via systemic thrombolysis (e.g., alteplase) or embolectomy.
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Topics

Pulmonary and Critical Care

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