key: cord-341060-otvoo99j
authors: Alharthy, Abdulrahman; Faqihi, Fahad; Papanikolaou, John; Balhamar, Abdullah; Blaivas, Mike; Memish, Ziad A.; Karakitsos, Dimitrios
title: Thrombolysis in severe COVID-19 pneumonia with massive pulmonary embolism
date: 2020-07-30
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.07.068
sha: 
doc_id: 341060
cord_uid: otvoo99j

OBJECTIVE: No guidelines exist for the management of massive pulmonary embolism (PE) in COVID-19. We present a COVID-19 patient with refractory acute respiratory syndrome (ARDS), and life-threatening PE who underwent successful thrombolysis. CASE PRESENTATION: A previously healthy 47 year old male was admitted to our hospital due to severe COVID-19 pneumonia [confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR)]. He had rapidly evolving ARDS [partial arterial pressure of oxygen to fractional inspired concentration of oxygen ratio: 175], and sepsis. Laboratory results showed lymphocytopenia, and increased D-dimer levels (7.7 μg/ml; normal: 0–0.5 μg/ml). The patient was treated in the intensive care unit. On day-1, ARDS-net/prone positioning ventilation, and empiric anti-COVID treatment integrating prophylactic anticoagulation was administered. On hospital day-2, the patient developed shock with worsening oxygenation. Point-of-care-ultrasound depicted a large thrombus migrating from the right atrium to the pulmonary circulation. Intravenous alteplase (100 mg over 2 h) was administered as rescue therapy. The patient made an uneventful recovery, and was discharged to home isolation (day-20) on oral rivaroxaban. CONCLUSION: Thrombolysis may have a critical therapeutic role for massive PE in COVID-19; however the risk of potential bleeding should not be underestimated. Point-of-care ultrasound has a pivotal role in the management of refractory ARDS in COVID-19.

J o u r n a l P r e -p r o o f evolving ARDS [partial arterial pressure of oxygen to fractional inspired concentration of oxygen ratio: 175], and sepsis. Laboratory results showed lymphocytopenia, and increased Ddimer levels (7.7 mcg/ml; normal: 0-0.5 mcg/ml). The patient was treated in the intensive care unit. On day-1, ARDS-net/prone positioning ventilation, and empiric anti-COVID treatment integrating prophylactic anticoagulation was administered. On hospital day-2, the patient developed shock with worsening oxygenation. Point-of-care-ultrasound depicted a large thrombus migrating from the right atrium to the pulmonary circulation. Intravenous alteplase (100 mg over two hours) was administered as rescue therapy. The patient made an uneventful recovery, and was discharged to home isolation (day-20) on oral rivaroxaban.

Thrombolysis may have a critical therapeutic role for massive PE in COVID-19; however the risk of potential bleeding should not be underestimated. Point-of-care ultrasound has a pivotal role in the management of refractory ARDS in COVID-19.

Keywords: COVID-19, massive pulmonary embolism, thrombolysis, acute respiratory distress syndrome, point-of-care ultrasound.

Recently, a preliminary analysis of a large US cohort of critically ill patients with severe novel SARS-CoV-2 disease (COVID-19) has suggested the benefit of systemic anticoagulation on their J o u r n a l P r e -p r o o f anticoagulation in patients with severe COVID-19, and Padua prediction score ≥4 or D-dimer>3.0 μg/mL has been previously suggested due to the increased occurrence of pulmonary embolism (PE) [3, 4] . Scarce data exist though about the use and safety of thrombolysis for massive PE in patients with COVID-19. Herein, we are briefly discussing the case of a critically ill COVID-19 patient who underwent thrombolysis for life-threatening PE.

A previously healthy 47 year old male was admitted to our emergency department due to severe 

Suppl. Video 1. Point-of-care-cardiac ultrasound modified four-chamber view (day-2) revealing a large thrombus in a dysfunctional right heart "en-route" to the pulmonary circulation in our critically ill COVID-19 patient.

Suppl. Video 2. Point-of-care-cardiac ultrasound modified four-chamber view (day-5) depicting no thrombi in the right heart, and normalization of right ventricular function in our critically ill COVID-19 patient.

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