clinical investigations incritical care Diagnosis andTreatment ofShockDue toMassive Pulmonary Embolism* Approach WithTransesophageal Echocardiography andIntrapulmonary Thrombolysis

Study objectives: Toevaluate thediagnostic value oftransesophageal echocardiography (TEE) as an initial diagnostic tool inshocked patients. Thesecondobjective was tostudy therapeutic impact ofintrapulmonary thrombolysis inpatients withdiagnosed massivepulmonary embolism. Design: Prospective observational study. Setting: Medical ICUin800-bed general hospital. Patients: Twenty-four consecutive patients withunexplained shock anddistended jugular veins. Measurements andmainresults: In 18patients, right ventricular dilatation withglobal or segmental hypokinesis was documented. Inaddition, central pulmonary thromboemboli (12 patients), reduced contrast flowinright pulmonary artery (one patient), andright ventricular freewallakinesis (onepatient) were found. No additional echocardiographic findings were apparent infourpatients. According topulmonary scintigraphy orautopsy, sensitivity ofTEEfor diagnosis ofmassivepulmonary embolism (MPE) inpatients withright ventricular dilatation was 92%andspecificity was 100%.Inpatients without right ventricular dilatation, left ventricular dysfunction (four patients) or cardiac tamponade (two patients) was confirmed. Intrapulmonary thrombolysis was evaluated in11of13patients withMPE.Twopatients diedprior toattempted thrombolysis. Threepatients received streptokinase andeight received urokinase. Twenty-four hours after beginning oftreatment, total pulmonary resistance indexsignificantly decreased for 59%andmean pulmonary artery pressure for31%.Cardiac index increased for74%.Nineof11 patients receiving thrombolysis survived tohospital discharge. Conclusion: Bedside TEE isa valuable toolfordiagnosis ofMPE. Itenables immediate intrapulmonary thrombolysis, which seems tobean effective therapeutic alternative inour group ofpatients withobstructive shock. (CHEST 1997; 112:1310-16)