21 Year young male, went to his physician with compliant DOE and palpitation. Pateint was send to Cardilologist for ECHO. ECHO finding were suggestive of Pulmonary embolism , RA RV Dilated with normal LV function.Immediate CTPA- WAS done which confirmed PE. Pateint was given 18 mg reteplase bolus. At that time ,HR130, BP 130/80, SPO2 85% (RA). blood reports came after reteplase was given which showed platelet count 14,000, and HB 10GM%. REST of the routine reports were normal. Now patient was shifted under my care after these report came. when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).
This patient fall in category of chronic sub massive ( moderate PE). As he was not in shock, not acidotic, not in perarrest condition, not severe RV Dysfuction. Evidence do not support use of thrombolytics in MODERATE PE( clinicaly stable patient. Thogh thrombocytopenia report came later but retrospectively it look the pateint was just lucky that he did not bleed with such a low platelet count.
As he was shifted to my care immedietely post thromolysis ,there was neither any clinical improvementt or deterioration.
Post thromolytic ECHO showed RA/RV Dilated , PASP (50 ), WITH NORMAL LV function.
when patient came to me His Heart rate 132, BP 120/70, SPO282%( RA) but patient is breathing comfortably ( RR-24).
Patient responded to Oxygen ( 15litre NRVM) ,SPO2 99%, As he was non acidotic , and hemodynamicaly stable , we planned to manage further with LMWH . Workup sarted for thrombocytopenia and thrombophilia. He was found to have (APLA & ACLA) postive with ADsDNA postive . Steroid and HCQs was strtaed for same . His platelet stated improving after 24 hour. He was started on warf after 48 hours. It look 7 days to achieve INR OF 3.5 Then sropped LMWH. Platelets came to normal after 5 days.
With retrospective history ,he gave history of Cough and DOE since last 2 months.
We have discharged this patient on warf ( target INR :3.75-4.5), HCQS, WYSOLONE & Mycophenilate mofetil.
At discahge his HR-90, SPO2 (92%-94% ) on RA, BP 120/80, RR 18. PASP 40.
I am watchful , but it way be possible this Chronic , submassive PE patient may need surgical thrombectomy . I am not sure when I will advise for that . I believe to give 3 month trail of controlling SLE, AND MAITAINING INR of (3.75 to 4.5).
