Massive pulmonary embolus presenting with abdominal pain.

Editor

We present the case of a 20 year old man who presented to the emergency department of Craigavon Hospital with a one day history of abdominal pain and dyspnoea. He had been involved in a motorcycle accident three days previously and sustained a soft tissue injury to his left leg. Examination revealed lower abdominal tenderness and left calf swelling. Blood pressure was 140/53mmHg and oxygen saturations were 97% on room air. ECG showed sinus tachycardia (137 beats per minute) and 2mm upsloping ST segment elevation in leads V1-V4 (figure 1).

Fig 1

Ten minutes after arrival, he had an asystolic arrest. Cardiopulmonary resuscitation was commenced, 10 units of intravenous reteplase were administered and he transferred to the cardiac catheterisation laboratory. Myocardial infarction was thought unlikely, thus we proceeded first to pulmonary angiography which showed a large filling defect in the main pulmonary artery extending into left and right branches consistent with a saddle embolism (figure 2). Catheter manipulation and direct intra-embolus injection of further reteplase achieved slight clot fragmentation into smaller sub-branches, but no significant return of pulmonary artery flow or systemic circulation. The resuscitation attempt was discontinued after 90 minutes. Autopsy confirmed a left leg deep venous thrombosis, a saddle-type pulmonary embolism and normal coronary arteries.

Fig 2

This case highlights the often atypical presentation of pulmonary embolism1,2, the feasibility and value of early invasive pulmonary angiography even during cardiac arrest, but also the need for ongoing development of percutaneous techniques/devices for effective large-clot fragmentation or removal.