Critical Management of Haemodynamically Unstable Acute Pulmonary Embolism in COVID-19

Abstract

Thrombotic events occur in up to one-third of patients with COVID-19, predominantly manifesting as pulmonary emboli (PE), which are associated with higher morbidity and mortality. Acute PE should therefore be one of the main differential diagnoses of COVID-19 patients who develop hemodynamic instability. Early systemic thrombolysis remains the first line of treatment for hemodynamically unstable PE in those infected with COVID-19, particularly considering the risks of infection to other personnel during catheter-directed thrombolysis procedures. This report aims to describe a typical case of hemodynamically unstable acute PE with COVID-19 management in our center. A 66-year-old male presented to ER with shortness of breath and desaturation was suspected of having COVID-19. Despite unremarkable physical examination, he was later confirmed to be COVID-19 positive. While in the isolation ward, he experienced a cardiac arrest. 12-lead ECG showed sign of right ventricular strain and subsequently bedside echocardiography showed a fresh thrombus in the right atria with signs of acute right ventricular dysfunction. The diagnosis of acute PE with hemodynamic instability was made, and systemic thrombolysis was immediately initiated. Despite the bleeding complication, his symptoms and hemodynamic improved and he was discharged safely with oral anticoagulant. Our case demonstrates how early recognition and prompt treatment of acute PE especially in COVID-19 patients with hemodynamic instability, can be life saving. Recognizing the subtle signs of acute PE during emergency improves patients outcome considerably.