title: Circulatory collapse, right ventricular dilatation, and alveolar dead space: A triad for the rapid diagnosis of massive pulmonary embolism.
abstract: A triad of circulatory collapse, right ventricular dilatation, and large alveolar dead space is proposed for the rapid diagnosis and treatment of massive pulmonary embolism. A 17year-old female on oral contraceptives collapsed at home becoming incoherent with shallow breathing. Paramedics initiated mechanical chest compression and transported the patient to our emergency department, arriving minimally responsive with undetectable blood pressure but having positive corneal reflexes and bradycardia with wide QRS. The trachea was intubated and goal-directed echocardiography revealed marked right ventricular dilatation with septal flattening. The arterial PCO2was 40mmHg with an end-tidal PCO2of 8mmHg, revealing a large alveolar dead space. Persistent hypotension, bradycardia, and fading alertness despite epinephrine and norepinephrine infusions prompted resumption of chest compression. Intravenous alteplase (10mg bolus over 10min followed by 90mg over 110min) begun 125min after collapse improved hemodynamic function within 10min allowing discontinuation of chest compression. Five and a half hours after starting alteplase, the patient was hemodynamically stable and had normal end-tidal PCO2. A CT-angiogram showed the pulmonary arteries free of emboli but a thrombus in the right common iliac vein. The patient recovered fully and was discharged home on warfarin 8days later. Based on this and other reports, we propose a triad of circulatory collapse, right ventricular dilatation, and large alveolar dead space for the rapid diagnosis and treatment of massive pulmonary embolism, with systemic fibrinolysis as the first-line intervention.
authors.affiliation: Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States; Resuscitation Institute, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States. Electronic address: raul.gazmuri@rosalindfranklin.edu.
authors.forename: Raúl J
authors.initials: RJ
authors.lastname: Gazmuri
authors.affiliation: Pharmacy Service, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States.
authors.forename: Dimple J
authors.initials: DJ
authors.lastname: Patel
authors.affiliation: Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States.
authors.forename: Rom
authors.initials: R
authors.lastname: Stevens
authors.affiliation: Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States.
authors.forename: Shani
authors.initials: S
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000072226:Computed Tomography Angiography; D004106:Dilatation; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006439:Hemodynamics; D006801:Humans; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000188:drug therapy; D012126:Respiratory Dead Space; D012769:Shock / Q000000981:diagnostic imaging*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging*; D014859:Warfarin
chemical_list: D005343:Fibrinolytic Agents; D014859:Warfarin; D010959:Tissue Plasminogen Activator