Thanks to Dr. Paul Page for leading the discussions this month

All cases in this series are imaginary, but highlight learning points that have been identified as potential issues during rounds

Edited by Dr David Lewis 

Discussion Topics

1. Incomplete Abortion

   • Unstable patients require staff to staff direct communication. OBGYN staff are always in house.
   • Patients remain responsibility of EM attending staff during and after consult. Transfer of care occurs at admission.
   • Be aware of the pitfalls of handover and possible need to reassess patient depending on clinical situation

2. Cardiac Arrest – Pulmonary Embolism

   • Be aware of bias when seen patient in low acuity area
   • Alway consider and document a ‘top 3’ differential diagnosis
   • CPR must be extended after thrombolysis for suspected / confirmed PE
   • Consider following a standardized VTE pathway

Incomplete Abortion

Case

A 30yr old female presents with a profuse PV bleeding. She is 7 weeks pregnant by dates. She presents with abdominal pain, palor and is hypotensive and tachycardic. During fluid resuscitation, PV exam confirms the presence of blood and clots, the os is open and contains tissue. This is removed. The bleeding appears to stop. CBC identifies a low hemoglobin. The patient is transfused. What are the potential pitfalls in the management of this case?

First Trimester Bleeding – American Family Physician

Patient Information Leaflet

Management of Unstable Patients with 1st Trimester Bleeding

• Urgent Consult to OBGYN
• Management is similar to all unstable bleeding patients (resus room, monitors, vascular access, IV fluid +/- unmatched O neg blood, foley).
• Investigate for DIC.
• Tranexamic acid (1g IV) +/- oxytocin (40U by IV in 1L NS at 150cc/hour) can be given to slow bleeding before definitive management (in the OR).
• **In an unstable patient with massive vaginal bleeding, a pelvic exam is indicated to identify a source and to look for and extract tissue found in the cervix.**
• Any unstable patient who presents with 1st trimester bleeding and requires blood transfusion should be admitted, even if they stop bleeding in ED and the low Hb is corrected. There is potential for rebleed over next 24 hrs especially if products are retained.

Episode 23: Vaginal Bleeding in Early Pregnancy

Further Reading:

• Rapid Reviews EM Cases – Video
• Northwestern University Emergency Medicine – Clinical Concept: Managing first trimester vaginal bleeding in the ED
• CanadiEM Frontline Primer – Early Pregnancy – First Trimester Bleeding

CanadiEM Frontline Primer – Early Pregnancy – First Trimester Bleeding

Cardiac Arrest – Pulmonary Embolism

Case

A 68 yr old male is brought into the emergency department with chest pain and shortness of breath. The patient is diaphoretic and hypotensive. They report a 5 day history of progressive leg swelling prior to these new symptoms. During the initial assessment the patients has a cardiorespiratory arrest. What is the differential diagnosis? What is the management of cardiac arrest when PE is suspected

A retrospective study published in Arch Intern Med  – May 2000, found that PE was found as the cause in 60 (4.8%) of 1246 cardiac arrest victims over an 8 year period.The initial rhythm diagnosis was pulseless electrical activity in 38 (63%), asystole in 19 (32%), and ventricular fibrillation in 3 (5%) of the patients. Thrombolysis resulted in significantly higher rate of ROSC, however survival to discharge was very low.

Diagnosis of PE in cases of cardiac arrest is often difficult to establish. Clinical suspicion of PE as a cause of cardiac arrest remains the key in timely diagnosis and treatment. In this study sudden dyspnea and syncope were the most suggestive reported symptoms. Deep vein thrombosis is known to be an important risk factor for PE, but clinical signs of deep vein thrombosis are rare and nonspecific. Right bundle-branch block was present in 67% of these cases, and this should induce a high suspicion for massive PE as cause of cardiac arrest. The authors recommend either transthoracic or transesophageal echocardiography be performed at the bedside in all cases to help establish the diagnosis of PE as the cause of a cardiac arrest.

Management of Cardiac Arrest in Suspected PE

1. Commence CPR and follow the ACLS 2018 Algorithm
2. Suspicion for PE as cause of cardiac arrest?
3. Bedside Assessment to Increase Suspicion of PE as cause of cardiac arrest
4. Thrombolysis
5. VA ECMO + Interventional Radiology / Cardiovascular Surgery

1.  Commence CPR and follow the ACLS 2018 Algorithm

AHA ACLS 2018 Algorithms –  Update Highlights

2.  Suspicion for PE as cause of cardiac arrest?

• Sudden onset dyspnoea or syncope prior to cardiac arrest
• Right ventricular strain, new RBBB or other PE suggestive findings on ECG immediately prior to cardiac arrest
• Initial non-shockable rhythm
• History of immobilization prior to cardiac arrest (recent surgery, travel, injury)
• History of thromboembolism
• History of recent cancer diagnosis and treatment
• Known hypercoagulation condition (e.g. Factor V Leiden)
• No history of cardiac disease
• Age less than 50yrs
• Female
• Pregnancy or Birth Control
• Clinical signs of recent DVT (swollen leg, history of swollen/painful leg)

Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation

3.  Bedside Assessment to increase likelihood of PE as cause of cardiac arrest

• Clinical exam for signs of DVT
• Clinical assessment to exclude other reversible causes of cardiac arrest (5H’s and 5T’s)
• DVT PoCUS
• Transthoracic Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (must not delay CPR)
• Transesophageal Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (superior images, does not interfere with CPR)

4.  Thrombolysis

An retrospective study published in Chest in 2019 analysed thrombolysis in PE related out-of-hospital-cardiac arrest. They found that thrombolysis was associated with increased 30 day survival but that a good neurological outcome was rare and not significantly improved. This 2019 systematic review and meta-analysis concluded that systematic thrombolysis during CPR did not improve hospital discharge rate.

Despite a weak evidence base, both the European Resuscitation Council (ERC) as well as the American Heart Association (AHA) have recommend the use of fibrinolytic therapy when PE is either known or suspected as the cause of cardiac arrest.

AHA Recommendations – in refractory cardiac arrest where PE has either been confirmed or is suspected, thrombolysis is a reasonable emergency treatment option:

• Alteplase 50mg peripheral IV bolus
• Option to repeat the bolus at 15 mins
• Continue CPR for 30-60 minutes after lytic administration

EMCrit 261 – Thrombolysis during Cardiac Arrest

5.  VA ECMO + Interventional Radiology / Cardiovascular Surgery

Interventional and surgical procedures cannot be performed during CPR.

Several studies have concluded that ECMO can be beneficial in patients with PE related cardiac arrest

Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism

Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review

Resuscitation of prolonged cardiac arrest from massive pulmonary embolism by extracorporeal membrane oxygenation

Massive Pulmonary Embolism as a Cause of Cardiac Arrest: Navigating Unknowns in Life After Death

The consensus seems to be that in order to see benefit from the use of ECMO to bridge patients with massive PE / cardiac arrest a protocolized approach is required, including a standby ECMO team and predetermined pathways.

Further Reading

Submassive & Massive PE