Indications for Thrombolytic Therapy in Patients with Acute Pulmonary Embolism
A 28 year old woman with a history of systemic lupus erythematosus (SLE) and recurrent miscarriages presented to the emergency department (ED) with right sided chest pain and shortness of breath (SOB). On examination she had a pulse of 132, blood pressure of 98/60 and an oxygen saturation of 90% on 3L/min of supplemental oxygen (administered via a nasal cannula). The ED attending suspected pulmonary embolism (PE) and ordered a stat chest CT angiography. The chest CT revealed a large acute PE in the right pulmonary artery (PA) extending to the descending branch of the right PA. The patient was given a bolus of IV heparin then started on a heparin drip and admitted to the medical floor. Doppler ultrasound of the lower extremities was ordered to assess for deep vein thrombosis (DVT). A routine transthoracic echocardiogram (TTE) was also ordered to assess for right ventricular (RV) dysfunction and evaluate for pulmonary hypertension.
Eight hours following admission, before the Doppler ultrasound or TTE were obtained, the patient experienced worsening SOB. The nurse assigned to the patient contacted the respiratory therapist on duty and the patient’s physician. Based on the nurse’s report of the patient’s condition, the admitting physician consulted the pulmonologist on call for his opinion regarding thrombolytic therapy. Twenty minutes later when the pulmonologist arrived, the patient’s breathing was labored, her oxygen saturation was 88% on a non re-breather face mask, her pulse was 146, and her blood pressure was 83/48. The pulmonologist immediately requested an intubation kit and placed a stat order for tissue plasminogen activator (tPA). While the team was setting up the intubation tray and just as the pharmacist was entering the room with the tPA, the patient coded. Cardiopulmonary resuscitation was initiated and tPA was started. The patient failed to respond to resuscitation and died ten hours after admission. The patient’s family sued, alleging that the admitting doctor failed to recognize the patient’s clinical severity and failed to consult the pulmonary specialist and give tPA in a timely manner.
To read the patient safety discussion and learn more about thrombolysis click below.