1. Thrombolysis In PE

2. Case III  54 y male POD #1 LLL lobectomy ? Ca  PMH : HTN, A Fib, DM II, COPD  Rx : Digoxin, Lasix, Metformin, ASA enalapril & bronchodilator enalapril & bronchodilator  Post op SOB

3. History  Sudden onset of diaphoresis & SOB  No chest pain, fever, wheeze, cough  No abdominal or leg pain  500 NS & 1000 pentaspan was given  BP 75/55 baseline 120/70  BP 75/55 baseline 120/70

4. Examination  BP 80/55 HR 90 A fib RR 25 Temp 37 Sat 94% on 5 L O2 RR 25 Temp 37 Sat 94% on 5 L O2  Cool mottled skin, conscious +ve accessory muscles +ve accessory muscles  JVP difficult ? 5cm ASA  Epidural in place

5. Examination  CVS : S1+S2 ? S3  Chest : Clean wound Good AE No wheeze,crackles Good AE No wheeze,crackles Chest tube no air leak Chest tube no air leak  Abd & LL  NAD

6. Investigation  WBC 19 Poly 75% Hb 112 Plt & Coagulation N Hb 112 Plt & Coagulation N  Creat 115 K 2.9  ABG PH 7.43 PCO2 39 HCo3 22 PO2 135 on 7 L O2 PO2 135 on 7 L O2  CXR & CT

7. Hospital Course  Transferred to SICU  Intubated  hypoxia & Shock  ARF & Shocked liver  TEE  Dilated RV with RWMA LVEF 35% Pulmonary HTN LVEF 35% Pulmonary HTN  CK 5000 TnT 5 Lactate 18

8. Hospital Course  Received tPA Hb 100  80 No heparin INR 2.5 No heparin INR 2.5  CRRT  FIO2 55%  CI 3.2 on 1.5 mcg /kg Levo &.5mcg/kg Millrinone &.5mcg/kg Millrinone  Recurrent episodes of VT/ SVT  multiple DC shocks  multiple DC shocks

9. Hospital Course  OR pathology  Hamrtoma  Same condition for 3 days  Family meeting  Withdrawal of support

10. Thrombolysis In PE  Streptokinase RCT SK 1.5 million IU /1 hour Vs heparin 8 pt All 4 pt rx with heparin died postmortem shows massive PE All 4 with SK had hemodynamic improvement & alive at 2 y follow up J Thromb Thrombolysis. 1995 J Thromb Thrombolysis. 1995

11. Thrombolysis In PE  rtPA Chest. 1990 Dec RCT rtPA 40-80 mg over 90-120 mint VS Placebo 13 patient End point hemodynamic effect & clot resolution Initial improvement in rtPA PVR at 60 mint which didn’t last at 90 mint

12. Thrombolysis In PE  rtPA VS SK. RCT 90 pt 100 mg rtPA over 2hours Vs SK 24 hours Endpoint angiographic resolution at 2 hours & VQ at 2 days & VQ at 2 days No statistical difference in resolution 2 rtPA Vs 1 SK had ICH J Am Coll Cardiol july 92 J Am Coll Cardiol july 92

13. Thrombolysis In PE  rtPA bolus Vs 2 h infusion RCT 60 Pt rtPA bolus /15 mint maximum 50mg 27 Pt 100 mg over 2 hours Death 8.3 % Bolus Vs 3.7% Infusion P NS Chest. 94 Sep Chest. 94 Sep

14. Thrombolysis In PE  Alteplase Vs SK RCT 66 pt massive PE Mean PAP > 20 Either 2 h Alteplase or 2 h SK 48 h hemodynamics  SK faster reduction in MAP first 24h but at 48 h SK was equal 1 y follow up recurrence & death  equal JA Card 1998 Apr JA Card 1998 Apr

15. Thrombolysis In PE  Alteplase in submassive PE RCT 256 pt PE with resp or homodynamic instability 118 Alteplase + heparin Vs 138 heparin Inhospital mortality 3.2 Vs 2.2 P NS Clinical deterioration 10.2 Vs 24.6 P < 0.004 No major bleeding Minor bleeding In Alteplase NEJM oct 02 NEJM oct 02