Case presentation
A 43-year-old female initially presented to the emergency department
with shortness of
breath and syncope. She has a history of superficial DVTs, nicotine
dependency, and
morbid obesity. On presentation, she was alert and oriented with normal
neurological
findings. She had an elevated heart rate of over 120 with an oxygen
saturation of 90%
on 2L NC and was hemodynamically stable. Her labs were significant for
leukocytosis,
an elevated D-Dimer of 2.85ug/mL, BNP 17400 pg/mL, and an initial
troponin of
0.063ng/mL. An emergent chest-CT was performed which revealed large
bilateral
pulmonary emboli (Figure 1). The patient was subsequently started on
full-dose Lovenox and sent to the progressive care unit for further
evaluation and management. Overnight, the patient was noted to have an
episode of syncope that was associated with cyanosis, tremors, and
diaphoresis. At that time, her blood pressure was stable at 130/80 as
she remained mildly lethargic. As the patient did not meet formal
indications for systemic tissue plasminogen activator (tPA), she was
immediately transferred to the ICU for further evaluation and closer
monitoring of her symptoms. During the day, an
echocardiogram was performed which revealed a severely dilated right
atrium and
ventricle with a right ventricular systolic pressure of 66.2 mmHg
(Figure 2). The patient had fleeting episodes of bradycardia and
hypotension with a noted drop of over 40 mmHg in her systolic pressure
on slight movements. Given her rapid decompensation and being in rural
setting with limited resources, the patient was immediately transferred
to a facility capable of performing intervention catheter-directed
thrombolysis for treatment. Following the transfer, the patient was
pronounced deceased due to complications related to her condition.