Fatal Pulmonary Embolism

Report:

Sinus tachycardia 102/min

ST/T changes c/c infarction/ischæmia

Possible acute cor pulmonale

S1T3 pattern

Comment:

This is a difficult tracing. The modest ST elevation in V1-2 is associated with what looks like reciprocal ST depression in inferolateral leads. Yet it could “pass” for a cor pulmonale which should certainly be mentioned if any clinical data were available.

These data were virtually diagnostic: a 150 Kg man with 5-day history of diarrhœa and 2 day history of severe dyspnœa, hypoxic with clear chest X-ray! A V/Q scan was planned on the ward, but he was hypotensive and transferred to CCU for r-tPA, once the penny dropped. It was too late: he arrested with probable RV infarction (Fig 89a below) and could not be resuscitated. Of course the infarction could also be an anteroseptal/inferior one, depending on the anatomy of his LAD artery; it matters little.

Autopsy confirmed massive pulmonary embolisation and advanced triple vessel coronary artery disease. There was no time for histological infarct changes to occur.

The case illustrates the difficulty in differential diagnosis; the sad part is that both potentially fatal conditions considered in Casualty could have been treated then and there with the same drug.