Low-dose systemic thrombolysis in patient with recent major abdominal surgery and high-risk pulmonary embolism: Case report and narrative review

Introduction: Systemic thrombolysis is the treatment of choice for hemodynamically unstable patients with acute pulmonary embolism (PE) while for the intermediate-high risk ones the possibility of severe bleeding seems to outweigh the benefits. Surgical or percutaneous therapy is an option in case of contraindication/failure of fibrinolysis but they are not available in every hospital. Case Report: An 85-year-old woman arrived at the Emergency Department for rapid onset dyspnea, thoracic pain with hypotension, tachycardia, and hypoxia. A computed tomography pulmonary angiography revealed acute PE of the main branches of the pulmonary right and left arteries. Due to hemodynamic instability and a history of recent intestinal resection surgery (25 days before), a continuous infusion of low-dose thrombolysis regimen with 50 mg rt-PA in 2 hours was started. After 30 minutes of rt-PA infusion, all vital signs were improved and at the end of rt-PA infusion. Point of care ultrasound (POCUS) revealed a reduced size of right ventricle with a decrease in right/left ventricle ratio. Hospital stay and a follow-up at two weeks revealed no complication due to the fibrinolytic administration or anticoagulant therapy. Conclusion: Anticoagulation is still the cornerstone therapy for patients with PE, but there’s a lack of trials on reperfusion strategy. Moreover, different guidelines give different short-term risk classifications, indication, and dosage of thrombolytic drugs and absolute and relative contraindications to systemic thrombolysis. This case report shows the potential benefit of low-dose rt-PA in patients with relative contraindications to thrombolysis and presenting with vital signs compatible with hemodynamic instability

Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma

Abstract Background The aim of this study is to describe point-of-care ultrasound and Color flow Duplex Doppler characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck. Methods Penetrating and blunt trauma-related vascular injuries such as vein disruption, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae are discussed in this manuscript. Images of the most significant lesions of our personal clinical experience are presented to illustrate point-of-care ultrasound and Color flow Duplex Doppler ultrasound findings. Results Penetrating and blunt trauma-related vascular injuries represent a big challenge. While patients with hard signs of arterial damage must be sent immediately to surgical exploration, when there are soft signs or no clear signs of vascular injury at the physical examination, and the patient is stable, imaging investigation and observation can be useful in the diagnosis and management of these patients. Although angiography is the gold standard of the imaging methods, point-of-care ultrasound and Color flow Duplex Doppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain. They can provide bedside valuable information for the identification of some vascular injuries allowing to an integrated management of the trauma patient, enriched by the use of ultrasound. Conclusions Point-of-care ultrasound and Color flow Duplex Doppler examination are increasingly used in the decision making process of trauma-related vascular injuries

Thirty and ninety days mortality predictive value of admission and in-hospital procalcitonin and mid-regional pro-adrenomedullin testing in patients with dyspnea. Results from the VERyfing DYspnea trial

Introduction: Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea. Methods: To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF). Results: Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P <.001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P <.0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR- proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days. Conclusions: In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days. (C) 2014 Elsevier Inc. All rights reserved