Dr. Chew Kiat Yeoh
EMSJ DalEM PoCUS Fellow
Privacy note: This is case is imaginary and includes components from various cases seen by the author over the last 5 years. It is presented in this way for educational purposes.
EMSJ DalEM PoCUS Fellow
Privacy note: This is case is imaginary and includes components from various cases seen by the author over the last 5 years. It is presented in this way for educational purposes.
Dr. Kendra MacCuspic
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
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?
Threatened abortion |
Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and closed cervix |
Spontaneous abortion |
Spontaneous loss of a pregnancy before 20 weeks’ gestation |
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Complete abortion |
Complete passage of all products of conception |
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Incomplete abortion |
Occurs when some, but not all, of the products of conception have passed |
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Inevitable abortion |
Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable |
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Septic abortion |
Incomplete abortion associated with ascending infection of the endometrium, parametrium, adnexa, or peritoneum |
First Trimester Bleeding – American Family Physician
CanadiEM Frontline Primer – Early Pregnancy – First Trimester Bleeding
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.
AHA ACLS 2018 Algorithms – Update Highlights
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:
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
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.