Biography: Abdalazeem Ibrahem
Introduction: Pulmonary embolism (PE) can be associated with arrhythmias. Ventricular fibrillation is reported to be associated with PE, but rare with high mortality and poor outcomes. We report a case of 67-year-old gentleman who presented with syncopal episode. On day three of admission, he was found to be in ventricular fibrillation, ALS algorithm was followed. When reversible conditions were explored, thromboembolism was falsely ruled out because of ECHO results on admission. Bed side ECHO performed to rule out cardiac tamponade, which showed multiple large echogenic mobile mass consistent with PE.
Conclusion: ALS (advanced life support) algorithm remains vital in exploring reversible conditions during cardiac arrest. Never be reassured by the previous normal results. Simple bed side ECHO gives a lot of information in emergency situation.
Case description: 7-year-old gentleman presented to emergency department with syncopal episode. He doesn’t have any significant past medical history. He has significant alcohol intake and lives alone. On admission he was hemodynamically stable, no significant abnormality on systemic examination.
Initial investigations: CRP 120mg/L, WCC 12.2 x 109, HB 113 mg/dl, Urea and electrolytes normal, serial Troponin I 1560, 1189.
ECG: Atrial fibrillation with LBBB.
CXR: Right mid zone consolidation/mass (further imaging advised).
Bed side ECHO: Dilated cardiomyopathy, EF 20-25%.
Initial diagnosis: Community acquired pneumonia, newly diagnosed arrhythmia (AF) and Dilated cardiomyopathy.
Discussion: Pulmonary embolism common condition resulting in cardiac arrest in many patients. Thrombolysis performed at appropriate time results in improvement of overall mortality rate. Literature shows pulmonary embolism is mostly associated with pulseless electrical activity, right ventricular strain pattern but it can be associated with any kind of arrhythmias, some common than the other. In our case the embolic event is associated with ventricular fibrillation, which is rare but reported. Always have a high suspicion of pulmonary embolism in any arrhythmia, vague symptoms resulting in haemodynamic compromise situation. A bed side ECHO showed evidence of PE, which was thrombolysis appropriately. This massively improved the clinical outcome. This case again reemphasis about the ALS algorithm, exploring reversible conditions to improve the overall mortality. It’s safe to have high suspicion of thromboembolic event in any patient with cardiac arrest (even when the investigations show normal results). Re-think all the reversible conditions and rule out individually in the current situation rather than relying on the investigations on admission. Bedside simple ECHO can give lot of information in establishing a cause of cardiac arrest, when performed by qualified individual without interrupting CPR, if in progress.