Obstructive shock in pulmonary embolism: thrombolytic therapy and survival
© Current Science Ltd 1999
Published: 16 March 2000
Shock due to massive pulmonary embolism (PE) shows a variable prevalence in literature, without general agreement about thrombolytic therapy effectiveness. Objective of the study was to appreciate prevalence and main clinical features of obstructive shock (OS) in patients with PE admitted to our departement, and to evaluate thrombolytic therapy effectiveness (BAPE regimen).
Methods and results
236 PE cases were treated from March 95 until June 98; 24/236 suffered OS (10.2%, 14 F, 10 M, mean age 69 years). In 91.6% of OS we found one risk factor, at least, and in 62% two or more risk factors. 3/24 patients presented with cardiac arrest, 7/24 showed RBBB and 5/24 S1Q3T3 pattern on EKG, 9/24 showed a normal EKG. Echocardiography, performed in 66% of patients, detected in all cases an enlarged and hypokinetic right ventricle; venous duplex ultrasound, performed in 70% of cases, detected DVT in 70.5%; perfusion radionuclide lung scan, performed in 70.5% of cases, showed a high probability pattern in 94%. D-dimer was altered in all cases; ABG analysis showed hypoxemia in all cases.
13/24 patients with OS were given thrombolysis according to BAPE regimen (rTPA 0.6 mg/kg over 15 min); 11/24 patients with OS were not given thombolysis because of absolute contraindications. Thrombolytic therapy decision-making rested on clinical data, on echocardiography in 38% of case and on echocardiography and lung scan in 61% of cases. Intra-hospital overall death-rate was 37.5% (9/24 patients); all 13 patients given thrombolysis were alive at discharge, whereas, 9/11 (81.8%) patients not given thrombolysis died in the hospital.
We found OS in 10.2 % of PE cases; 13 patients given thrombolysis all were alive and showed stable hemodynamic parameters at discharge, whereas 9/11 patients not thrombolysis given died during hospital stay. This outlines the need of an expeditious clinical and instrumental diagnosis as a tool of decision-making, especially about thrombolytic therapy. Moreover, we found a 100% sensibility of D-dimer, hypoxemia as detected by ABG analysis, echocardiography and perfusion radionuclide lung scan.