Diagnosis and Treatment of Shock Due to Massive Pulmonary Embolism: Approach With Transesophageal Echocardiography and Intrapulmonary Thrombolysis

doi:10.1378/chest.112.5.1310

Chest

Volume 112, Issue 5, November 1997, Pages 1310-1316

https://doi.org/10.1378/chest.112.5.1310 Get rights and content

Study objectives

To evaluate the diagnostic value of transesophageal echocardiography (TEE) as an initial diagnostic tool in shocked patients. The second objective was to study therapeutic impact of intrapulmonary thrombolysis in patients with diagnosed massive pulmonary embolism.

Design

Prospective observational study.

Setting

Medical ICU in 800-bed general hospital.

Patients

Twenty-four consecutive patients with unexplained shock and distended jugular veins.

Measurements and main results

In 18 patients, right ventricular dilatation with global or segmental hypokinesis was documented. In addition, central pulmonary thromboemboli (12 patients), reduced contrast flow in right pulmonary artery (one patient), and right ventricular free wall akinesis (one patient) were found. No additional echocardiographic findings were apparent in four patients. According to pulmonary scintigraphy or autopsy, sensitivity of TEE for diagnosis of massive pulmonary embolism (MPE) in patients with right ventricular dilatation was 92%; and specificity was 100%;. In patients without right ventricular dilatation, left ventricular dysfunction (four patients) or cardiac tamponade (two patients) was confirmed. Intrapulmonary thrombolysis was evaluated in 11 of 13 patients with MPE. Two patients died prior to attempted thrombolysis. Three patients received streptokinase and eight received urokinase. Twenty-four hours after beginning of treatment, total pulmonary resistance index significantly decreased for 59%; and mean pulmonary artery pressure for 31%;. Cardiac index increased for 74%;. Nine of 11 patients receiving thrombolysis survived to hospital discharge.

Conclusion

Bedside TEE is a valuable tool for diagnosis of MPE. It enables immediate intrapulmonary thrombolysis, which seems to be an effective therapeutic alternative in our group of patients with obstructive shock.

Section snippets

MATERIALS AND METHODS

Consecutive patients with unexplained circulatory shock admitted to our ICU from July 1993 to February 1996 were included. The inclusion criteria were clinical signs of peripheral hypoperfusion (anuria/oliguria, peripheral cyanosis, cold and pale skin), systolic BP below 90 mm Hg, and distended jugular veins. None of the patients had previous chest trauma.

TEE using 5-MHz monoplane probe (Sonos 1000; Hewlett-Packard; Andover, Mass) was performed within 15 min after admission and served as

RESULTS

The study enrolled 24 patients (Fig 1). Right ventricular dilatation with global or segmental hypokinesis and leftward bulging of interatrial septum was documented in 18 patients. In these patients, central thromboemboli (12 patients), reduced contrast flow (one patient), and right ventricular free wall akinesis (one patient) were seen. No additional echocardiographic findings were present in four patients. In patients without right ventricular dilatation, either left ventricular dysfunction

DISCUSSION

Our study demonstrated that TEE is a very useful bedside diagnostic tool in the setting of unexplained shock with distended jugular veins. Detection of central thromboemboli, aortic dissection, segmental akinesis, and pericardial tamponade accounted for specific findings that were essential to establish the correct diagnosis. In addition, TEE provided important information regarding right and left ventricular function in each patient.

TEE proved to be particularly useful in patients with right

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Citation Excerpt :
Transesophageal echocardiography may be useful in patients with suspected massive PE who require immediate and aggressive therapy.56 Because of the high prevalence of bilateral central thromboemboli in such patients, transesophageal echocardiography allowed definitive diagnoses in 92%.56 Other than in patients with massive PE, transesophageal echocardiography had limited accuracy in comparison with CT.57
The clinical diagnosis of pulmonary embolism (PE) is difficult in coronary care units (CCUs) because many findings of PE are similar to those of acute coronary syndromes and heart failure. Immobilization of only 1 or 2 days may predispose to PE. Heart failure and acute myocardial infarction add to the risk. Dyspnea may be absent or occur only with exertion. The onset of dyspnea may occur over seconds to days. Orthopnea occurs with PE as well as heart failure. When the clinical probability and results of objective testing are discordant, the posttest probability of PE may be neither sufficiently high nor sufficiently low to permit therapeutic decisions. Objective scoring systems for clinical assessment have not been developed for patients in a CCU. d-dimer is likely to be of little value for the exclusion of PE in CCUs, because elevations occur with heart failure, unstable angina, and myocardial infarction. Computed tomographic pulmonary angiography with venous phase imaging of the low pelvic and proximal leg veins (computed tomographic venography) is recommended for imaging. Scintigraphy in women aged <50 years with normal or nearly normal results on chest x-ray may be the preferred imaging test to reduce the risk for radiation. Echocardiography with leg ultrasonography is a rapidly obtainable combination of bedside tests that may be useful for young patients and patients in extremis. In conclusion, the choice of diagnostic test depends on the clinical probability of PE, the condition of the patient, the availability of diagnostic tests, the risks of iodinated contrast material, radiation exposure, and cost.

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: Reprint requests: Bojan Krivec, MD, Dept of Intensive Internal Medicine, General Hospital Celje, Oblakova 5, Celje 3000, Slovenia

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Chest

Clinical Investigations in Critical CareDiagnosis and Treatment of Shock Due to Massive Pulmonary Embolism: Approach With Transesophageal Echocardiography and Intrapulmonary Thrombolysis

Study objectives

Design

Setting

Patients

Measurements and main results

Conclusion

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Chest

Am J Cardiol

J Am Soc Echocardiogr

Lancet

Chest

Clinical Investigations in Critical Care
Diagnosis and Treatment of Shock Due to Massive Pulmonary Embolism: Approach With Transesophageal Echocardiography and Intrapulmonary Thrombolysis