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.