I'd caution calling it a 100% lethal PE and jumping on the lytics until we know for sure that we didn't pop a lung or cause a vfib by irritating an already irritable mycoardium (Right Ventricular MI hasn't been ruled out yet) with the guidewire. so while yes start CPR, at least hold the lytics in your hand and listen to the lungs and glance up at the monitor. And then at least try a round of CPR before giving lytics. If you get too cowboyish with the 100mg tPA or whatever you want to use, you're just gonna kill the guy when he does have a massive retroperitoneal bleed and massive hemothorax and you sheepishly realized all you needed was electricity or finger poked into the pleural space. Not saying not to use it at all. Just hold off for a minute or two and think if there's anything else to do since this guy does have pretty strong contraindications to lysis.
Just so everyone knows, Rendar is not a plant.
There are some bits of information that I didn't go into detail on that people want to know in order to make their decisions. Some of these data points I didn't include because I didn't want premature diagnostic fixation, some because I didn't have the information available yet, and some because I never got the info. In no particular order:
ORL10: Pt was in T-berg when he became unresponsive and lost his pulse. It was an U/S guided IJ into a honking R IJ so I felt pretty good about not having dropped the lung. I'm pretty shallow about how far I put in the wire (we have the kits where you thread the wire through the syringe and needle) and I didn't see any ectopy monitor during the procedure. I never actually got to sew in the line, but that's more of an aside than a plot point.
dchristismi: he's in PEA, he got epi and chest compressions which he liked. At this point radiologist calls me back and tells me he sees B PEs (noted on my look through the lungs) but nothing else acute (I scanned through to pelvis with run-off from the PE protocol). And after 2 rounds of epi and ~5 min of CPR he gets ROSC.
Continuing the case:
I intubated him without event. Now I'm open to discussing that he should have been tubed prior but he was oxygenating well and I thought having a very clear look into his mental status was worth the metabolic demand from his work of breathing. He was complaining of some abdominal pain on arrival and continued to complain of it until he coded so until CT took retroperitoneal hemorrhage off the table. All of this contributed to the diagnostic uncertainty and being able to communicate with him helped somewhat.
So I was ready to push lytics if they had been available during the code, but now he's got ROSC and while he doesn't have a current bleed his risk for intra-abdominal hemorrhage is huge. So he's gone done once, popped back up relatively quickly and is looking stable-ish. He's on heparin already, and his pressure is in the mid 90's on a levophed gtt. Still waiting for the OSH transfer center to answer the damn phone. I relook at the CT on our PACS and while the emboli themselves aren't huge, most of his lung is black on CT (I can't identify any subsegmental and maybe one segmental branch that are opacified).
Still waiting for the tPA to come from pharmacy (which I had ordered after the 1st round of epi hadn't worked) when he codes again. Epi, CPRx6 minutes, and up'ing his levophed result in ROSC again. Vascular surgeon from OSH calls back, accepts the patient to transfer by air, and asks whether you're going to give IV t-PA.
???
