Sudden Cardiopulmonary Collapse in a Patient With Coronavirus Disease 2019.

A 76-year-old man presented to the ED with reports of diarrhea, cough, and fever of 1 week duration, preceded by close contact with a friend who had tested positive for severe acute respiratory syndrome coronavirus 2.

The patient’s initial vital signs were as follows: heart rate, 104 beats/min; BP, 124/86 mm Hg; respiratory rate, 28 breaths/min; and peripheral oxygen saturation, 86% on room air. Bilateral rales were present on physical examination. Chest radiography revealed bilateral diffuse airspace disease (Fig 1 ), and results of testing for severe acute respiratory syndrome coronavirus 2 were positive. Urine pneumococcal and legionella antigens, as well as the remainder of the respiratory viral pathogen panel, were negative. Supplemental oxygen was provided via nasal cannula 5 L/min, correcting the patient’s hypoxemia, and he was admitted to the ICU. The initial transthoracic echocardiogram revealed a hyperdynamic left ventricle with normal right ventricular size and function. On day 5 of hospitalization, the patient acutely decompensated and developed worsening hypoxia (peripheral oxygen saturation, 76%), tachycardia with a heart rate of 124 beats/min, and shock with a BP of 84/50 mm Hg. Pressor support was initiated during preparations for intubation. Point-of-care ultrasonography (POCUS) was performed to further evaluate the decompensated state (Video 1).

Figure 1

Chest radiography demonstrating an alveolar-interstitial pattern.

Question: Based on the clinical scenario and the findings on POCUS, what is the most likely diagnosis in this patient?

Answer: Acute pulmonary embolism, with cor pulmonale, in the setting of an alveolar-interstitial syndrome

During the evaluation, the patient experienced cardiac arrest with an initial rhythm of pulseless electrical activity, and advanced cardiopulmonary life support was initiated. Alteplase was administered as a 50 mg IV bolus. Return of spontaneous circulation was achieved after 4 min of CPR.

Discussion

Coronavirus disease 2019 (COVID-19) results in a spectrum of disease ranging from a viral syndrome to severe acute respiratory syndrome and ARDS. Reports also indicate a cytokine storm leading to multiorgan failure and shock, hypercoagulability, and cardiac dysfunction. , Although an overwhelming majority of respiratory decompensation in COVID-19 is related to the development of severe acute respiratory syndrome/ARDS, the treating intensivist must consider other diagnoses, as they would with all critically ill patients. Pneumothorax, cardiogenic shock, pericardial tamponade, and thromboembolic disease remain potential sources of collapse that can be rapidly identified with POCUS.

As expected with an alveolar-interstitial syndrome, the typical pattern seen on pleural ultrasonography is a B-line pattern or, more specifically, a B-line pattern with an erratic or irregular pleural surface, suggesting an inflammatory, noncardiogenic pulmonary edema (Fig 2 ). As the pulmonary disease progresses, consolidation may be identified. In addition to B lines, our POCUS findings identified acute cor pulmonale, demonstrated by a severely dilated right ventricle, a D-shaped septum, and a collapsed left ventricle. The visualization of clot in transit in the right atrium shifted the differential diagnosis and therapy from that of isolated ARDS to include massive pulmonary embolism (Video 2, Discussion Video).

Figure 2

B-line pattern with an erratic pleural line. Point-of-care ultrasonography correlate of an inflammatory alveolar-interstitial pattern. Circled is the erratic pleural line.

The increased use of POCUS and echocardiography for differentiation of shock and risk stratification of pulmonary embolism has increased the detection of right heart thrombi (RHT). RHT are detected echocardiographically in approximately 4% of patients with acute symptomatic pulmonary embolism. In a meta-analysis of > 15,000 patients with acute symptomatic pulmonary embolism, patients with concomitant RHT had a threefold increased risk of death. Similarly, findings from the Right Heart Thrombi European Registry showed that in patients with RHT and right ventricular dysfunction, 30-day mortality increased from 7% to 16% compared with those with right ventricular dysfunction alone. The presence of RHT has been associated with double the frequency of right ventricular hypokinesis, increased systolic pulmonary artery pressure, elevated biomarkers (troponin and brain natriuretic peptide levels), and reduced tricuspid annular plane systolic excursion.

Hospital diagnostics such as vascular studies, CT imaging, and echocardiography may not be rapidly available 24 h a day, making POCUS (consisting of vascular, cardiac, thoracic, and abdominal imaging) an essential resource when treating the critically ill. Furthermore, transferring unstable patients to diagnostic studies poses an additional risk that can potentially be avoided with the use of POCUS. This remains especially true during the COVID-19 pandemic. POCUS should be regarded as an instrumental tool and may be one of the only diagnostic imaging modalities that can be rapidly deployed and repeated to help in timely diagnosis of cardiopulmonary collapse and organ failure.

Reverberations

Dual diagnosis for cardiopulmonary collapse is frequent in critical illness and can often be identified with POCUS.

RHT is diagnostic for venous thromboembolic disease and portends a higher mortality when associated with shock and right ventricular dilation.

POCUS should be regarded as an essential, rapidly accessible, imaging modality within the ICU.