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  Medline 		Missouri Chapter
Missouri Resident Poster Competition 1999

Kamala Tamirisa M.D.             ST. LOUIS UNIVERSITY  
Diagnosis of acute pulmonary embolism using pulmonary 
artery catheter   
 

Diagnosis of acute pulmonary embolism using pulmonary artery catheter

A 48 year old male firefighter was admitted due to respiratory failure following an
explosive fire accident and acute lung injury. He was intubated and aggressively 
treated for carbon monoxide inhalation. Radiological imaging was negative for fractures.
DVT prophylaxis was initiated with heparin and pneumatic compression stockings.
The patient improved over the next 3 days, although he remained intubated for airway 
protection.

On the third day of hospitalization, he decompensated with severe hypoxia and hypotension
 which remained resistant to oxygen, fluids and vasopressors. 
Lab results: ABG – 7.37/46 pCO2/ 75 pO2/93% on 70% FIO2; Chest X-Ray, EKG and cardiac enzymes were negative; CBC and chemistry remained unchanged; Duplex scan of the lower extremities was negative for DVT. Simultaneously, a PS catheter was floated and the following
 tracing was obtained.

Severe pulmonary hypertension with normal pulmonary capillary wedge pressure was noted consistent with acute pulmonary embolism. There was a 12-mm gradient of pressure between
 distal and proximal PS suggestive of saddle embolus. Heparin was initiated and the diagnosis confirmed by lung perfusion scan. Transthoracic echocardiogram revealed a right atrial thrombus. Patient was emergently treated with thrombolytics with successful resolution of hypoxia and hypotension. The PA catheter tracing no longer showed a gradient in the pulmonary artery. A
 repeat echocardiogram showed resolution of the thrombus. Over the next few days, the patient
 was extubated and subsequently discharged home on long term anticoagulation.

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