Pulseless electrical activity in acute massive pulmonary embolism during thrombolytic therapy

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1 Cse Report Tzu Chi Medicl Journl 2017; 29(1): Pulseless electricl ctivity in cute mssive pulmonry embolism during thrombolytic therpy Hn-Hu Yu, Jing-Ren Jeng b* Deprtment of Internl Medicine, Buddhist Tzu Chi Generl Hospitl nd Tzu Chi University, Hulien, Tiwn, b Deprtment of Crdiology, Buddhist Tzu Chi Generl Hospitl nd Tzu Chi University, Hulien, Tiwn Received : Revised : Accepted : Abstrct We report cse of cute pulmonry embolism with hemodynmic instbility dignosed by computed tomogrphy pulmonry ngiogrm. The ptient developed pulseless electricl ctivity during systemic thrombolytic therpy with recombinnt tissue plsminogen ctivtor. Successful return of spontneous circultion ws chieved fter immedite crdiopulmonry resuscittion with chest compressions for 6 min. His electrocrdiogrm (ECG) on rrivl in the emergency deprtment displyed sinus tchycrdi, n S wve in led I, Q wve in led III, incomplete right bundle brnch block (RBBB), T-wve inversion (TWI) in leds V1 V3, ST elevtion in leds VR nd V1, nd ST depression in leds I, II, III, VF, nd V4 V6. These chrcteristic ECG chnges might hve prognostic vlue for clinicl deteriortion. He recovered fter tretment. After dischrge, the ECG showed resolution of TWI in leds V1 V3 nd incomplete RBBB, suggesting recovery from right ventriculr dysfunction, which ws confirmed by n echocrdiogrm on follow in the outptient deprtment. Keywords: Acute pulmonry embolism, Crdiopulmonry resuscittion, Electrocrdiogrphy, Pulseless electric ctivity, Thrombolytic therpy Introduction Acute pulmonry embolism (PE) is common clinicl disese with very high mortlity (52%) in ptients who re hemodynmiclly unstble [1,2]. Prompt dignosis nd pproprite therpy for unstble ptients my reduce the mortlity of mssive PE [1,2]. A computed tomogrphy pulmonry ngiogrm (CTPA) nd bedside trnsthorcic echocrdiogrm (TTE) re often performed to confirm the dignosis of PE. Clssic electrocrdiogrm (ECG) chnges in ptients with cute PE include the S1Q3T3 pttern, T wve inversion (TWI) or ST devition in the precordil or inferior leds [3] nd right bundle brnch block (RBBB), s mrker for min pulmonry trunk embolus [4]. Recently, Zhong-Qun et l [5]. reported new ECG pttern tht ws observed in three ptients with cute PE during hemodynmic instbility. The chrcteristic ECG chnges of cute PE fter clinicl deteriortion re ST elevtion (STE) in led VR with concomitnt ST depression (STD) in leds I nd V4 V6. This ECG pttern in fvor of unstble PE Quick Response Code: Access this rticle online Website: my help clinicins in the rpid identifiction of high risk ptients who cn benefit from erly thrombolytic therpy, surgicl thrombectomy or ctheter-directed removl nd/ or lysis of the thrombus. Thrombolytic therpy is very useful in treting n cute mssive PE tht cuses hemodynmic instbility [2]. However, its efficcy cn be reduced by crdic rrest which further promotes thrombosis nd restricts ccess of thrombolytic gents. When hemodynmic collpse complictes n cute mssive PE in ptient under thrombolytic therpy, immedite crdiopulmonry resuscittion (CPR) my improve the efficcy of the thrombolytic gent. Becuse the right ventricle (RV) is primrily volume pump, it cnnot respond effectively to cute, lrge occlusion of the pulmonry rteries *Address for correspondence: Dr. Jing-Ren Jeng, Deprtment of Crdiology, Buddhist Tzu Chi Generl Hospitl, 707, Section 3, Chung-Yng Rod, Hulien, Tiwn. E-mil: jrj4511@gmil.com This is n open ccess rticle distributed under the terms of the Cretive Commons Attribution-NonCommercil-ShreAlike 3.0 License, which llows others to remix, twek, nd build upon the work non-commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com DOI: /tcmj.tcmj_7_17 How to cite this rticle: Yu HH, Jeng JR. Pulseless electricl ctivity in cute mssive pulmonry embolism during thrombolytic therpy. Tzu Chi Med J 2017;29: Tzu Chi Medicl Journl Published by Wolters Kluwer - Medknow

2 (PAs). Vigorous mnul chest compression my support the circultion during the initil criticl stte when the thrombolytic gent hs been dministered but hs not yet tken effect. Recently, Nobre et l [6]. reported tht 4 of 6 ptients with in-hospitl crdic rrest during thrombolytic therpy for cute mssive PE survived fter CPR with prolonged mnul chest compressions. It ws emphsized tht vigorous chest compression could improve systemic perfusion, counterct the prothrombotic stte ssocited with crdic rrest, nd give the thrombolytic gent time to ct. In this pper, we reported ptient with cute hemodynmiclly unstble PE who presented with chrcteristic ECG findings, developed pulseless electivity ctivity (PEA) during systemic thrombolytic therpy with recombinnt tissue plsminogen ctivtor (r-tpa), survived fter immedite CPR with 6 min of mnul chest compression, recovered well, nd finlly showed resolution of these ECG chnges, suggesting recovery of RV dysfunction, on follow-up fter dischrge from the hospitl. Cse report A 65-yer-old mn who hd history of hypertension, smoking nd drinking lcohol, complined of sudden onset of dyspne, chest pin, dizziness, cold sweting, wtery dirrhe, nd generl wekness fter plying mhjong for 4 h in the morning. He immeditely clled for help on his mobile phone nd ws sent to locl hospitl, where his blood pressure (BP) ws only 82/41 mmhg. Acute coronry syndrome ws first considered, so spirin 300 mg nd clopidogrel 300 mg were prescribed. He ws trnsferred to our emergency deprtment, where his BP ws 103/80 mmhg, pulse rte 102/min nd respirtory rte 24/min. There were no physicl signs of deep vein thrombosis in his legs. His ECG showed sinus tchycrdi, left tril enlrgement, n S wve in led I, Q wve in led III, incomplete RBBB, TWI in leds V1 V3, STE in leds VR nd V1, nd STD in leds I, II, III, VF, nd V4 V6, [Figure 1]. Bedside TTE disclosed dilttion of the RV nd right trium. A chest rdiogrph showed no widening of the ort or pulmonry edem. Bsed on the symptoms, ECG, chest rdiogrphy nd bedside TTE findings, cute mssive PE ws highly suspected. CTPA confirmed mssive emboli in the left nd right PAs [Figure 2] nd showed the RV/left ventricle (LV) dimeter rtio ws bnormlly incresed to 1.22 [Figure 2b]. Within 40 min fter rrivl in our ED nd initition of intrvenous (IV) heprin, his BP dropped to 61/40 mmhg nd he lost consciousness. He received emergency endotrchel tube intubtion for respirtory filure nd dopmine infusion titrted to 7 26 μg/kg/min to keep his BP round 100/70 mmhg. He ws then dmitted to our intensive cre unit nd given r-tpa 10 mg by IV bolus, followed by 50 mg IV drip over 30 min nd 40 mg IV drip over 90 min. During the thrombolytic therpy, crdic rrest with PEA occurred nd CPR ws performed immeditely. Successful return of spontneous circultion (ROSC) ws chieved fter mnul chest compression for 6 min. The lbortory dt showed his serum troponin I ws 0.61 µg/l, D-dimer 4956 ng/ml, cretinine 2.0 mg/dl, glucose 213 mg/dl, sprtte minotrnsferse 350 IU/ml, lnine minotrnsferse 78 IU/ml, lctic dehydrogense 313 IU/L, nd lctte 4.6 mmol/l. Heprin ws continued nd overlpped with orl wrfrin strting on the 6 th hospitl dy, when the vsopressor nd ventiltor were successfully wened. Heprin ws then discontinued when the prothrombin time interntionl normlized rtio reched 2.5. He recovered nd ws dischrged from the hospitl on wrfrin 5 mg nd vlsrtn 80 mg dily. A subsequent ECG in our outptient deprtment (OPD) showed resolution of TWI in leds V1 V3 nd incomplete RBBB [Figure 1b]. A lung scn nd Figure 1: The electrocrdiogrm on rrivl shows sinus tchycrdi, incomplete right bundle brnch block, left tril enlrgement, n S wve in led I nd Q wve in led III, T wve inversion in leds V1 V3, ST elevtion in leds VR nd V1, nd ST depression in leds I, II, III, VF, nd V4 V6, indicting hemodynmic instbility from n cute pulmonry embolism (). The electrocrdiogrm fter hospitl dischrge revels resolution of T wve inversion in leds V1 V3 nd incomplete right bundle brnch block, suggesting recovery from the right ventriculr dysfunction (b) b 51

3 b Figure 2: Computed tomogrphy pulmonry ngiogrphy discloses lrge emboli in the left nd right pulmonry rteries () nd the right ventricle/ left ventricle dimeter rtio is bnormlly incresed to 1.22 (b), confirming the dignosis of cute mssive pulmonry embolism echocrdiogrm t 32 dys reveled mild heterogenous distribution of rdioctivity in the bilterl lung fields nd norml RV chmber size (2.1 cm) with fir RV systolic function bsed on tricuspid nnulr plne systolic excursion (2.5 cm) nd RV frctionl re chnge (45%). The estimted systolic pulmonry rteril pressure (SPAP) ws 37 mmhg. There were no further complictions such s chronic thromboembolic pulmonry hypertension, fter 18 months follow-up in the OPD with orl wrfrin therpy. Discussion Our ptient hd only wek risk fctors for venous thromboembolism, including immobiliztion due to prolonged sitting, hypertension, incresed ge nd smoking [1], nd no physicl signs of deep vein thrombosis. Acute mssive PE ws suspected by bedside TTE showing dilted RV nd further confirmed by CTPA with lrge thrombi in the bilterl PAs. His ECG displyed chrcteristic chnges suggesting hemodynmic instbility nd high risk of mortlity. In cute PE, the ECG is often bnorml nd findings re neither specific nor sensitive, limiting its dignostic vlue [7]. However, these ECG chnges cn help strtify risk nd determine prognosis once the dignosis is mde. In 2001, Dniel et l [8]. creted 21-point ECG scoring system whereby points re ssigned for the following chnges (number of points in prentheses): sinus tchycrdi (2), incomplete RBBB (2), complete RBBB (3), TWI in leds V1 V4 (0 12), n S wve in led I (0), Q wve in led III (1), inverted T wve in led III (1), nd entire S1Q3T3 complex (2). With crdic compenstion, the ECG score is low if the thrombus occluding the PA is smll. Without crdic compenstion, the ECG score is high if the thrombi re lrge [7]. The scoring system hs shown significnt positive correltion with SPAP in cute PE. A high ECG score is useful mrker in predicting RV dysfunction. At cut-off of 10 points, the ECG score is 98% specific for the recognition of SPAP >50 mmhg. A score less thn 4 points cn exclude RV dysfunction nd resolution of TWI in leds V1 V3 my indicte recovery from RV dysfunction [9]. In recent yers, severl ECG bnormlities not included in the historicl 21-point ECG score hve gined ttention for prognostic potentil in cute PE, including STE in leds III, V1 nd VR nd STD in leds I, VL, nd V4 V6. In 2013, Zhong-Qun et l [5]. found tht severl combintions of ECG findings, including STE in led VR with concomitnt STD in leds I nd V4 V6 nd STE in leds III nd/or V1/V2 with concomitnt STD in leds V4 V6, predicted development of hemodynmic instbility. In 2014, Kukl et l [10]. reported tht STE in t lest one of leds III, VR nd V1 V4 or STD in t lest two lterl leds ws ssocited with mortlity in cute PE. These ECG chnges in cute PE re probbly induced by rpid pressure overlod, dilttion, nd dysfunction of the RV due to occlusion of the PA by mssive emboli, resulting in decresed RV outflow nd reduced LV prelod. Ischemi of the RV, myocrdium nd conduction system, hypoxemi, nd the effects of ctecholmines nd histmine re lso relted to the ECG chnges [11]. In our cse, the ECG showed STE in leds VR nd V1 nd STD in leds I, II, III, VF, nd V4 V6, in ddition to 14 point ECG score (sinus tchycrdi, incomplete RBBB, Q in III, TWI in leds V1 V3), indicting high SPAP nd RV dysfunction with gret risk of clinicl deteriortion due to respirtory filure nd progressive shock. Thrombolytic therpy with r-tpa 100 mg IV infusion for 2 h is dvised for ptients with persistent hypotension due to mssive PE or recurrent PE despite 52

4 nticogultion (Clss I, Level B) [1]. Our ptient ws in shock, so 60 mg r-tpa ws given in 30 min followed by 40 mg in 90 min, similr to its use for cute myocrdil infrction, with the nticiption tht erly onset of the thrombolytic effect would sve his life. If unstble PE ptients hve contrindictions to or filure of systemic thrombolytic therpy, surgicl embolectomy is recommended (Clss I, Level C) nd ctheter-directed reperfusion tretment is n lterntive choice (Clss II, Level C) ccording to the 2014 guidelines of the Europen Society of Crdiology [1]. In 2016, Cho et l [12]. in their smll retrospective experience reported tht surgicl embolectomy ws ssocited with lower crdic mortlity thn systemic thrombolysis for ptients with mssive PE without lifelimiting comorbidities. Percutneous ctheter-bsed interventions, if performed in n experienced center, re pproprite for ptients with mssive PE who hve contrindictions to systemic full-dose thrombolysis nd re unsuitble for surgicl embolectomy [13]. Ctheter intervention techniques, including conventionl nd ultrsound-enhnced ctheter-directed thrombolysis, thrombus frgmenttion with pigtil or peripherl blloon ctheter, rheolytic thrombectomy with n AngioJet ctheter, suction embolectomy with multipurpose ctheter, nd rottionl thrombectomy with n Aspirex S ctheter, hve been used with n 87% clinicl success rte in unstble PE [1,13]. In crdic rrest where mssive PE is strongly suspected, there is consensus tht thrombolysis should be considered [14]. In 2015, O Connor et l [15]. reported tht the use of double boluses of r-tpa 50 mg in 20 min for ptient with suspected mssive PE during PEA resulted in successful ROSC. Once thrombolysis is initited for suspected PE in crdic rrest, guidelines suggest tht CPR should be continued for t lest min [6,16]. In the report by Nobre et l [6]., prolonged, vigorous chest compressions were effective for PEA which occurred with mssive PE during thrombolytic therpy. Becuse the RV is proximl to the sternum nd even more proximl when dilted, chest compressions my ugment the RV output nd the circultion of r-tpa to enhnce its thrombolytic effect. However, if CPR fils to chieve ROSC quickly in mssive PE during PEA, extrcorporel membrne oxygention (ECMO) support cn be pplied s lifesving djunct to definitive tretment. In the cohort reviewed by Yusuff et l [17]., the use of ECMO in criticlly ill ptients with mssive PE ws ssocited with n overll survivl of 70.1% but those with crdic rrest hd higher risk of deth t rte round 48.8%. In our cse, crdic rrest with PEA complicted thrombolytic therpy for unstble PE, but successful ROSC ws chieved fter immedite CPR with 6 min of chest compressions iding thrombolysis. The resolution of TWI in leds V1 V3 nd incomplete RBBB on ECG fter hospitl leds dischrge suggested recovery from RV dysfunction, which ws further confirmed by n echocrdiogrm on follow up in our OPD. Conclusion We described ptient with cute mssive PE demonstrting chrcteristic ECG chnges tht might hve prognostic vlue for hemodynmic instbility nd clinicl deteriortion. For ptients with unstble PE nd crdic rrest with PEA during thrombolytic therpy, immedite CPR with chest compressions could be beneficil for ugmenttion of thrombolysis nd ROSC. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. Declrtion of ptient consent The uthors certify tht the ptient hve obtined pproprite ptient consent form. In the form the ptient hs given his consent for his imges nd other clinicl informtion to be reported in the journl. The ptient understnds tht his nme nd initil will not be published nd due efforts will be mde to concel their identity, but nonymity cnnot be gurnteed. References 1. Konstntinides SV, Torbicki A, Agnelli G, Dnchin N, Fitzmurice D, Gliè N, et l ESC guidelines on the dignosis nd mngement of cute pulmonry embolism. Eur Hert J 2014;35: , k. 2. Stein PD, Mtt F. Thrombolytic therpy in unstble ptients with cute pulmonry embolism: Sves lives but underused. Am J Med 2012;125: Yeh KH, Chng HC. Mssive pulmonry embolism with nterolterl ST-segment elevtion: Electrocrdiogrm limittions nd the role of echocrdiogrm. Am J Emerg Med 2008;26:632. e Petrov DB. Appernce of right bundle brnch block in electrocrdiogrms of ptients with pulmonry embolism s mrker for obstruction of the min pulmonry trunk. J Electrocrdiol 2001;34: Zhong-Qun Z, Chong-Qun W, Nikus KC, Sclrovsky S, Cho- Rong H. A new electrocrdiogrm finding for mssive pulmonry embolism: ST elevtion in led VR with ST depression in leds I nd V(4) to V(6). Am J Emerg Med 2013;31:456.e Nobre C, Thoms B, Sntos L, Tvres J. Prolonged chest compressions during crdiopulmonry resuscittion for in-hospitl crdic rrest due to cute pulmonry embolism. Tex Hert Inst J 2015;42: Digby GC, Kukl P, Zhn ZQ, Pstore CA, Piotrowicz R, Schpchnik E, et l. The vlue of electrocrdiogrphic 53

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