Direct-acting oral anticoagulants (DOACs) are prescribed in the treatment of venous thromboembolism, including pulmonary embolism (PE). Evidence is limited regarding the outcomes and optimal timing of DOACs in patients with intermediate- or high-risk PE treated with thrombolysis. We conducted a retrospective analysis of outcomes among patients with intermediate- and high-risk PE who received thrombolysis, by choice of long-term anticoagulant agent. Outcomes of interest included hospital length of stay (LOS), intensive care unit LOS, bleeding, stroke, readmission, and mortality. Descriptive statistics were used to examine characteristics and outcomes among patients, by anticoagulation group. Patients receiving a DOAC (n = 53) had shorter hospital LOS compared to those in warfarin (n = 39) and enoxaparin (n = 10) groups (mean LOS 3.6, 6.3 and 4.5 days, respectively; P < .0001). This single institution retrospective study suggests DOAC initiation <48 h from thrombolysis may result in shorter hospital LOS compared to DOAC initiation ≥48 h ( P < .0001). Further larger studies with more robust research methodology are needed to address this important clinical question.

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Objectives To describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE). Case presentation A 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits. Conclusions In the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.