Salvage intraosseous thrombolysis and extracorporeal membrane oxygenation for massive pulmonary embolism

Abstract

Intraosseous access is an alternative route of pharmacotherapy during cardiopulmonary resuscitation. Extracorporeal membrane oxygenation (ECMO) provides cardiac and respiratory support when conventional therapies fail. This case reports the use of intraosseous thrombolysis and ECMO in a patient with acute massive pulmonary embolism (PE). A 34-year-old female presented to the emergency department with sudden onset severe shortness of breath. Due to difficulty establishing intravenous access, an intraosseous needle was inserted into the left tibia. Echocardiography identified severe right ventricular dilatation with global systolic impairment and failure, indicative of PE. Due to the patient's hemodynamic compromise a recombinant tissue plasminogen activator (Alteplase) bolus was administered through the intraosseous route. After transfer to the intensive care unit, venous-arterial ECMO was initiated as further therapy. The patient recovered and was discharged 36 days after admission. This is the first report of combination intraosseous thrombolysis and ECMO as salvage therapy for massive PE.

Keywords: Cardiac arrest; extracorporeal membrane oxygenation; intraosseous; pulmonary embolism; thrombolytic therapy.

Figure 1

Mobile chest X-ray displaying oligemic lung fields

Figure 2

Computerized tomography pulmonary angiogram (arterial phase, axial slice) demonstrating persisting pulmonary embolus in a branch of the left pulmonary artery (arrow)