Pulmonary Embolism: The Daily PANCE Blueprint
A 62-year-old male presents to the ER with acute onset of shortness of breath. CTA chest demonstrates a saddle embolism. The echocardiogram shows RV dilation and severely reduced RV systolic function. The patient declines and starts to require vasopressors. Which of the following is an appropriate intervention?
A. Systemic thrombolytics
B. Heparin drip
C. VA ECMO alone
D. Impella RP
E. Dobutamine
Answer and topic summary
The answer is A. Systemic thrombolytics
The most common cause of acute cor pulmonale is a massive pulmonary embolism (PE). Cor pulmonale is defined by right ventricle failure/enlargement due to a pulmonary issue. The reason a pulmonary embolism leads to acute right heart failure is because a PE is a mechanical obstruction that increases vascular resistance in the lungs and increases RV afterload. The RV can’t unload sufficiently, which results in the dilation of the RV. The dilated RV can impede on the LV, leading to decreased LV output and decreased blood supply to the coronary arteries. It also causes RV wall tension/pressure to build and thus coronary perfusion is impeded to the right heart, further leading to ischemia. Additionally, the dilation of the RV can lead to tricuspid regurgitation, which reduces blood flow even more. As the RV becomes ischemic, it can’t contract as well and this further decreases RV output and LV output — leading to a dangerous cycle toward cardiogenic shock.
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
Also covered in the Emergency Medicine and Internal Medicine EOR content blueprint
