DIFFICULTIES IN DECISION-MAKING WHEN PROVIDING CARE TO PATIENTS WITH MASSIVE PULMONARY EMBOLISM AND OBSTRUCTIVE SHOCK (THE EXPERIENCE OF THE MARIINSKY HOSPITAL)

Abstract

Introduction. Pulmonary embolism (PE) is one of the most common cardiovascular accidents with a fairly high mortality rate. The development of unstable hemodynamics (obstructive shock) in a patient with PE, up to circulatory arrest, significantly worsens the prognosis and increases mortality. Algorithms for the management of such patients remain inconsistent; the prevalence of obstructive shock with PE in Russia is practically not covered in the literature. Materials and methods. The medical records of 19 patients from 33 to 94 years old, hospitalized at the Mariinsky City Hospital with pulmonary embolism and hemodynamic instability or circulatory arrest, were analyzed. Results. To confirm PE, echocardiography was performed (10 patients, 52.6%), of which 2 were performed in the shock room (signs of overload of the right chambers of the heart were detected), 7 in the intensive care unit (in 28.6% patterns of overload of the right chambers of the heart were not visualized), 1 patient was performed on the 18th day from admission during treatment. Thrombi in the right chambers of the heart were not visualized in patients. To search for the source of thrombosis, ultrasound examination of the veins of the lower extremities was performed (n=16); deep vein thrombosis of the lower extremities was detected in 56.3%. A CT scan to confirm pulmonary embolism was performed on all patients within an average of 62 minutes, except for two patients who were admitted with circulatory arrest and were subsequently declared to have a fatal outcome in the setting of acute medical conditions. Half of the patients received prehospital anticoagulant therapy;  thrombolytic therapy was performed in 47.3% of patients (n=9). In 2/3 of cases, thrombolytic therapy was carried out after transporting patients to the intensive care unit with tissue plasminogen activator and forteplase drugs for an average of 2.5 hours (from 90 to 210 minutes) from the moment of admission. Mortality was 63.2% (n=12), of which 16.7% of patients died in the emergency department within 60 minutes, 33.3% — within 6 hours in the intensive care unit, 16.7% — within 6–24 hours. In 33.3% of deaths, the number of days of hospitalization ranged from 2 to 18. Conclusion. The complexity of managing such patients is due to the need for a quick response from a multidisciplinary team of hospital admission departments, timely verification of pulmonary embolism, and assessment of indications and contraindications for thrombolytic therapy.