POCUS after PEA arrest

23/02/2021 3 Comments by Christopher Schott

Here is another, quick post. It is from a patient that had a PEA arrest with ROSC. Echo obtained upon patient arrival to ICU. What are your thoughts? How would you proceed, both for further workup (if any) and treatment?

-Christopher

Tags:

PEA, POCUS, Resuscitation, massive pulmonary embolism, PE, in transit

Comments (3)

Faraaz Shah

says:

Thu, 02/25/2021 - 11:00am

I see on multiple views an echogenic opacity in the right ventricle. I could not fully appreciate the left ventricle but on the subxiphoid views I was concerned about a small appearance of the LV, though I could not confirm on other cuts. In the setting of a PEA arrest, I would be most concerned about a clot in transit. I would call the PE team with consideration for clot retrieval/removal by IR or CT surgery.

Zaffar Haque

says:

Fri, 02/26/2021 - 11:13am

Clot in transit. Activate CT-Surgical Service, with VA-ECMO Backup.
The Clot is too big for EKOS. Alternatively, can administer TPA, with CT-Surgery/Embolectomy/VA-ECMO as backup.

cks16

says:

Tue, 03/02/2021 - 3:58pm

Hey everyone!

Thanks for your comments on this post! In these views, you are able to see an echogenic structure in the right atrium. Given the clinical context, there was high suspicion for embolism/ clot in transit. Once stabilized, a CTA no longer saw the clot in the heart, and radiology read confirmed massive PE.

Given the clinical context of PEA arrest, this would be a time to strongly consider tPA +/- VA ECMO:

Igneri LA, Hammer JM. Systemic Thrombolytic Therapy for Massive and Submassive Pulmonary Embolism. J Pharm Pract. 2020 Feb;33(1):74-89. doi: 10.1177/0897190018767769. Epub 2018 Apr 19. PMID: 29673293.

Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M; “MOPETT” Investigators. Moderate pulmonary embolism treated with thrombolysis (from the "MOPETT" Trial). Am J Cardiol. 2013 Jan 15;111(2):273-7. doi: 10.1016/j.amjcard.2012.09.027. Epub 2012 Oct 24. PMID: 23102885.

Thanks for sharing the case! If you have other interesting cases to post, be sure to reach out! We will have another post soon!

-Christopher

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POCUS after PEA arrest