Intraoperative Pulmonary Embolism
Sudden ↑PA pressure → RV failure → cardiovascular collapse. May be thrombus, fat (long-bone fracture, IM rod), gas (laparoscopy CO₂, sitting craniotomy), or amniotic.
⚡ Rehearsal mode
Walk the algorithm step by step
7 steps · click-through one at a time. Forces you to pre-read each action before moving on — the way you should rehearse the real thing.
Recognition
- •Sudden ↓ETCO₂ + ↓SpO₂ + ↑CVP + tachycardia
- •Hypotension, ECG changes (RBBB, S1Q3T3)
- •Bedside TEE: dilated RV, septal flattening, McConnell's sign
- •Air embolism: 'mill-wheel' murmur, sudden CV collapse
Steps
- 1100% FiO₂; deepen anesthesia if hemodynamics permit
- 2Hemodynamic supportNorepinephrine first-line (preserves SVR/PVR ratio). Add inotrope if RV failing.
- 3Avoid LR/excessive volumeRV is already overloaded; further preload worsens septal shift.
- 4Inhaled vasodilatoriNO 20–40 ppm or inhaled epoprostenol — selectively reduce PVR.
- 5Anticoagulation (if no surgical contraindication)Heparin bolus 80 U/kg + infusion.
- 6Consider thrombolysis (TPA) if cardiac arrest + suspected PETPA 50 mg over 2 min during arrest.
- 7VA-ECMO bridge to thrombectomy/lytics if available
Drugs + doses
| Drug | Dose | Note |
|---|---|---|
| Heparin | 80 U/kg IV bolus, then infusion to aPTT 60–80 | |
| Norepinephrine | 0.05–1 mcg/kg/min | |
| Epinephrine | 0.02–0.5 mcg/kg/min if RV failure | |
| Inhaled NO | 20–40 ppm | |
| Alteplase (TPA) | 50 mg IV bolus during arrest |
Pitfalls
- !Volume loading the failing RV worsens it. Resist 'just give fluid'.
- !Air embolism: head-down + left-lateral + aspirate from CVC may help.
Sources
- ESC PE Guidelines 2019
- AHA Scientific Statement 2011
Anatomy reference
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Other crisis algorithms
- Malignant Hyperthermia (MH)
Hypermetabolic crisis triggered by volatile anesthetics or succinylcholine in genetically susceptible patients (RYR1, CACNA1S). Treat with dantrolene immediately.
- Perioperative Anaphylaxis
IgE-mediated (or pseudo-allergic) hemodynamic collapse from drug, latex, or transfusion exposure. Most common triggers in OR: NMBAs (rocuronium, succinylcholine), antibiotics, latex.
- Amniotic Fluid Embolism (AFE)
Rare, often fatal obstetric emergency — anaphylactoid syndrome of pregnancy. Sudden hemodynamic collapse, hypoxemia, and DIC during labor, delivery, or postpartum (within 30 min).
- LAST (Local Anesthetic Systemic Toxicity)
Cardiovascular and CNS toxicity from inadvertent IV injection or systemic absorption of local anesthetic. Bupivacaine highest cardiotoxicity. Ropivacaine + lidocaine slightly safer.
- Laryngospasm
Reflex closure of the vocal cords from light-anesthesia airway stimulation. Common in pediatrics, recent URI, and emergence. Untreated → hypoxia → bradycardia → arrest.
- High / Total Spinal
Cephalad spread of neuraxial local anesthetic causing apnea + cardiovascular collapse. Most common with epidural-to-subarachnoid migration in OB.