CHEST Guidelines-A-70-Year-Old-Woman-With-Recent-Intracranial-Hemor

A-70-Year-Old-Woman-With-Recent-Intracranial-Hemor

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The document is a case study about a 70-year-old woman who experienced profound shock and was found to have an acute massive pulmonary embolism with a clot in transit, leading to acute right ventricular failure. She had a recent intracranial hemorrhage history, precluding the use of thrombolytic therapy, thereby necessitating urgent surgical intervention.<br /><br />Upon admission to the emergency department, she exhibited symptoms of vomiting and decreased responsiveness, along with hypotension unresponsive to fluid bolus. She had a medical history including hypertension, peripheral vascular disease, diabetes mellitus, and a significant smoking history. Initial examinations and laboratory tests showed left hemiparesis, pitting edema, elevated creatinine and lactate levels, and signs suggestive of cardiac stress.<br /><br />Critical care consultation and point-of-care ultrasonography revealed several issues: right ventricular overload, reduced left ventricular size, and a large echogenic mass in the right atrium consistent with a clot in transit. Additionally, compression ultrasonography indicated acute deep venous thrombosis. These findings pointed towards obstructive shock due to pulmonary embolism and right ventricular failure. <br /><br />Given her contraindication for thrombolysis, she was stabilized with norepinephrine and heparin drips and urgently transferred to the cardiac ICU. Within 12 hours, she underwent surgical thromboembolectomy, followed by placement of an inferior vena cava filter to prevent further emboli. Post-surgery, her condition improved dramatically, with significant recovery of right ventricular function as observed in follow-up echocardiography.<br /><br />The case highlights the critical role of ultrasonography in rapidly diagnosing shock mechanisms and guiding appropriate management, especially in high-risk patients where conventional treatments like thrombolysis are not suitable.

Keywords

pulmonary embolism

right ventricular failure

intracranial hemorrhage

surgical intervention

ultrasonography

deep venous thrombosis

cardiac ICU

thromboembolectomy

inferior vena cava filter

obstructive shock