1) A 44-year-old male presented with shortness of breath and was found to have acute pulmonary embolism based on CTPA findings. 2) He underwent thrombolysis with tenecteplase but became unresponsive and required CPR, however CT brain was negative for hemorrhage. 3) The patient's condition deteriorated and he was started on vasopressors, mechanical thrombectomy was performed, and eventually venoarterial ECMO was initiated due to hemodynamic instability.

1. CASE PRESENTATION
MODERATOR- DR. BHARATH KUMAR
PAMULAPATI
SPEAKER – DR.MANI PRASAD REDDY

2. CHIEF COMPLAINT
44 years male presented to ER on 8/2/23 with complaints of shortness
of breath since 7/2/23 evening.

3. History of present illness
• Complaints of shortness of breath since 1 day, grade 3.
• Not associated with cough, chest pain, pedal edema.
• In ER patient had tachycardia.

4. Past history –
Known case of PTE since 2019, was on Tab Xarelto 20mg OD till march 2020
Umbilical hernia S/P hernioplasty in 2020 march
 Family history – Insignificant
Personal history – alcoholic , Ex smoker
Allergic history – Nil

5. GENERAL EXAMINATION IN ICU
 Pallor,icterus,edema, Clubbing,cyanosis,lymphadenopathy are absent
 Temp – 99oF
RESPIRATORY SYSTEM -
Inspection - Abdominothoracic type of respiration. Chest is
symmetrical, Trachea central in position,
RR- 22,Equal rise of hemithorax
Palpation - All inspectory findings are confirmed.
Percussion – resonant note
Auscultation - Bilateral breath sounds heard.

6.  ABDOMINAL – Soft
No organomegaly
BS – present
CARDIOVASCULAR SYSTEM - S1S2 heard, No murmurs heard
HR-135/min , BP- 130/90mmhg
 Neurological system – GCS- E4V5M6
Pupils- B/L 2mm, Reacting to light
Power – 5/5 in all limbs
• Screening 2D ECHO – dilated RA/RV, TAPSE 1.2
• Screening lung USG – lung sliding +, no effusions, no B lines.

7. Provisional diagnosis
Acute pulmonary embolism

8. INVESTIGATIONS
HEMATOLOGICAL – CBP - Hb -15.8, TLC – 9600 , PLT – 249000
RFT – Sr cr – 1.06, BUN – 8.18, Sr Na – 145, K – 4.8, CL -99
LFT – SGOT – 19 SGPT – 27 Sr Alb- 3.8
CRP – 26.8
D dimer- 5.0, APTT- 23.50, PT- 11, INR- 1.0
 RADIOLOGICAL – CTPA showed acute PTE in main pulmonary trunk
extending into right and left pulmonary arteries, near total occlusion of
bilateral lobar arteries with extension into segmental arteries causing partial
occlusion.
ECG s/o sinus tachycardia

9. ECG

10. CTPA

11. ABG
• PH- 7.42,
• PCO2- 32.5,
• PO2-76.9,
• HCO3-22.5,
• BE -1.9,
• lac- 1.35

12. • Thrombolysis was done with IV Tenecteplase 40mg and shifted to
MICU for further management.
• Patient was shifted to ICU around 2:30 AM , at 4AM he had sudden
unresponsiveness and immediately airway secured , had PEA and CPR
done for 1 minute ROSC achieved and he became hemodynamically
unstable.
• CT brain plain was done to rule out IC bleed in v/o S/P thrombolysis
and it was negative.

13. ECHO after ROSC

14. 4:15 am 5:30 am 8:45 am 10:45 am
PH 6.77 7.116 7.086 7.109
PCO2 74.4 49.0 66.3 58.1
PO2 108.0 116.3 156.3 128.7
HCO3 7.4 14 15.6 15.2
Lactate 12.05 5.57 5.31 5.35

15. • Patient was started on noradrenaline and adrenaline and continued
on mechanical ventilation and inj Clexane 60 mg S/C BD was initiated.
• Mechanical thrombectomy (penumbra procedure) was done at 3pm
on 8/2/23.
• Patient became hemodynamically unstable and V-A ECMO initiated in
the night.

16. 8/2 9/2 10/2 11/2 12/2
TLC 28900 24400 17900 13100-10800
HB 11.6 9.8-8.4 8.5 8.4-8.5
PLT 168000 172000 145000- 123000 125000-116000
S.Cr 2.6 2.12 2.32 1.93
Na 141 150 145 151 146
K 3.0 3.9 4.80 4.40 3.6
TB 1.7 0.9 0.8
SGOT 326 80 31
SGPT 265 136 43
Sr.Alb 3.4 2.7 2.8
CRP 239.9 126.4 71.6

17. THANK YOU