If you haven’t read Part 1, get the story and the cool clips here first:  http://wp.me/p1avUV-ce

So the polls are in!  So far at least, 58% of you would blast away with full dose lytics, 26% with MOPETT-style half-dose, 10% content with heparin, and 5% would go for a PA catheter directed lysis.

So 90% would lyse this patient.  I’m glad to hear that, because in my opinion, more patients should be lysed than I see being done around me.

What did I do?  I went for the half-dose lytics, with an excellent result. Within a few hours she was much less dyspneic, BP was up to 110-120 systolic, and though RV dysfunction persisted, it was mostly resolved by the next day.  I think it is important to note that I had a long chat with her, explaining the risk of intracerebral hemorrhage, which I quoted as being less than 2%.  She opted for thrombolysis with the idea of averting cardiopulmonary limitation given her active lifestyle.

I think the physiological rationale for half-dose lytics is good, since, unlike when used for arterial lysis (coronary or cerebral) the entire dose will pass through the lungs. One could argue that the clot burden is larger,  but the resolution seen in MOPETT and in the dozen or so cases I’ve lysed (no intracerebral bleeds yet), rapid resolution of RV dysfunction supports a sufficient response.  I’ve yet to give – but am ready and willing – a “rescue” top-up 2nd half dose if the first hasn’t worked.

I think the other important point in this case is the importance of bedside ultrasound in the assessment of all shock patients. Although I have no doubt whatsoever that my competent colleague would have come to the diagnosis of PE, it may have been minutes to hours later, possibly after having to begin pressors for a lack of response to fluids.  I won’t hypothesize what might have happened in that time. Maybe nothing, maybe not.

She went home a few days later.

This is why the blind administration of fluid resuscitation is a growing pet peeve of mine.  Two litres in sepsis? Ok, probably, but not every shock is sepsis…  I think that in 2014, going on 2015, with virtually all ERs and ICUs equipped with an ultrasound, there is no place for the empiric bolus. It takes all of 5 seconds to look at an IVC, and another 15 to get an idea of cardiac function in most patients. Like a famous corporation says:

Opinions, rants and rotten tomatoes welcome!

cheers

Philippe