A 76-year-old woman with severe ischaemic heart disease being treated with aspirin, clopidogrel and metoprolol presents with severe abdominal and back pain, 6 hours after being discharged home from a routine cardiac angiogram via the femoral route.
A large retroperitoneal haematoma is diagnosed. After resuscitation, the bleeding is stopped by angiographic embolisation of a branch of the left internal iliac artery.
She is still in the intensive care unit 2 days later when she becomes suddenly dyspnoeic, hypoxaemic and hypotensive with a BP of 80 systolic.
b) What is your initial management?
Most likely cause is a pulmonary embolism but cannot rule out other causes. Resuscitation, relevant investigations and therapy go hand in hand. So, ABC Supplemental oxygen, fluid, then if inadequate response, consider appropriate vasoactive ie dobutamine/noradrenaline? Get an ECG, CXR, ABG. (D-Dimer of no use here due to large resolving haematoma) consider V/Q or more likely spiral CT scan to prove it.
This is a question about the management of sudden onset hypoxia and hypotension in the ICU.
PE is high on your list of differentials.
However, the college is looking for a systematic approach.
- Attention to ABCs, including immediate manageemnt of reversible factors, as well as a simultaneous focused physical examination and brief history
- ensure patency of the ETT and integrity of the ventilator circuit
- examine for tension pneumothorax
- examine for features of acute heat failure
- rapid bedside TTE to observe the volume and contractility of the chambers
- Supportive management
- high FiO2
- fluid boluses
- vasopressors and inotropes
- Specific investigations
- formal TTE