From massive pulmonary embolism to successful extracorporeal life support: Supportive role of point-of-care ultrasound.

Abstract

Background: Point-of-care ultrasound (POCUS) allows the clinician to accurately identify various types of shock and target therapeutic interventions accordingly in critically ill patients. In this report, we describe the rapid and opportune utilization of POCUS in diagnosing and treating a patient with a massive pulmonary embolism who required extracorporeal life support (ECLS). Case Presentation: A 45-year-old man presented to the emergency department with dyspnea, cough, and hemoptysis. A computed tomography angiography (CTA) of the chest performed at an urgent care clinic the same day showed near-completely occlusive emboli within the distal main pulmonary arteries bilaterally with suggested right ventricular strain. The comprehensive echocardiogram revealed dilated right ventricle (RV) with severely reduced systolic function. The patient was admitted to the intensive care unit (ICU) and treated with unfractionated heparin. As the patient was preparing for transfer to the medical ward on day 3 of hospitalization, he had an acute episode of near-syncope and soon became pulseless. An ECLS consult was activated for lack of sustained return of spontaneous circulation (ROSC) despite ongoing CPR and administration of tissue plasminogen activator (t-PA), crystalloids, epinephrine, and bicarbonate boluses. A POCUS performed by the intensivist showed organized cardiac activity with a severely dilated RV, flattened intraventricular septum, and underfilled LV in the absence of a detectable pulse, suggestive of pseudo-pulseless electrical activity. He was cannulated under real-time ultrasound guidance for establishing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to provide full cardiac support. His ICU course was complicated by bleeding and persistent RV dysfunction. Utilization of POCUS helped narrow the differential diagnoses for circulatory failure in the ICU course. The patient was weaned off ECMO support after 48 hours and discharged to a rehabilitation facility on hospital day 27 with intact neurologic function. Conclusion: This case describes a near-fatal complication of pulmonary embolism and highlights the importance of POCUS for rapid diagnosis of the etiology of cardiac arrest and timely initiation of ECLS. POCUS can complement the comprehensive echocardiogram and narrow the differential diagnoses during clinical deterioration. Intensivists should be proficient in acquiring, interpreting, and integrating POCUS into their clinical practice.