What is the management of a pulmonary embolism in a patient after injecting concrete into a vein?

Management of Pulmonary Embolism After Concrete Injection into Vein

Cement (polymethylmethacrylate) embolism causing pulmonary embolism requires primarily supportive treatment with anticoagulation, as the haemodynamic consequences are usually mild compared to thrombotic PE, though management must be escalated based on hemodynamic severity. 1

Initial Assessment and Risk Stratification

The first priority is determining hemodynamic stability to guide treatment intensity:

• High-risk PE (shock, sustained hypotension, or cardiac arrest) requires immediate aggressive intervention 1
• Intermediate-risk PE (hemodynamically stable but with right ventricular dysfunction on imaging or elevated biomarkers) requires close monitoring with potential for escalation 1
• Low-risk PE (hemodynamically stable without RV dysfunction) can be managed with anticoagulation alone 1

Assess for signs of right ventricular failure including distended jugular veins, right-sided S3 gallop, new right bundle branch block, or T wave inversion in leads V1-V4 2

Anticoagulation Management

Initiate unfractionated heparin (UFH) with weight-adjusted bolus (80 U/kg bolus followed by 18 U/kg/h infusion) immediately without delay, even while diagnostic workup is in progress. 1, 3

• For most hemodynamically stable patients, low molecular weight heparin (LMWH) or fondaparinux is preferred over UFH 1
• Transition to a direct oral anticoagulant (DOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban is recommended over vitamin K antagonists for long-term management 1

Critical caveat: While anticoagulation prevents further thrombotic complications, it does not dissolve the cement particles themselves—treatment is primarily supportive for non-thrombotic emboli 1

Hemodynamic Support for High-Risk Presentations

If the patient presents with shock or sustained hypotension:

• Administer norepinephrine and/or dobutamine immediately to maintain adequate cardiac output and coronary perfusion pressure 1, 3
• Avoid excessive fluid administration as this may worsen right ventricular distention and compromise left ventricular filling 4
• Consider milrinone as an alternative inotrope with additional pulmonary vasodilatory effects 4

Advanced Interventions for Severe Cases

Systemic thrombolytic therapy is recommended for high-risk PE with hemodynamic instability (alteplase 50 mg IV bolus with option for repeat in 15 minutes), though this primarily addresses any concurrent thrombotic component rather than the cement itself 1, 3

If thrombolysis is contraindicated or fails:

• Surgical pulmonary embolectomy is the definitive treatment for high-risk PE when medical management is insufficient 1
• Percutaneous catheter-directed treatment should be considered as an alternative 1
• ECMO may be considered in combination with surgical embolectomy or catheter-directed treatment in patients with refractory circulatory collapse or cardiac arrest 1

Monitoring and Supportive Care

• Continuously monitor heart rate, blood pressure, and oxygen saturation 4
• Perform bedside echocardiography to assess right ventricular function and severity of obstruction 4, 2
• Provide supplemental oxygen to maintain adequate oxygenation 5
• Consider pulmonary vasodilators such as inhaled nitric oxide or sildenafil for significant right ventricular dysfunction 4

Key Clinical Pitfalls

Do not delay anticoagulation while awaiting definitive diagnosis—begin treatment based on high clinical probability 1

Do not assume cement embolism will behave like massive thrombotic PE—the European Society of Cardiology notes that non-thrombotic emboli (including cement) usually cause milder haemodynamic consequences than thrombotic PE, though great variability exists 1

Do not prematurely terminate resuscitation in cardiac arrest cases—PE-related cardiac arrest requires prolonged CPR efforts of 60-90 minutes minimum 3

The cement particles themselves cannot be dissolved and remain entrapped within the pulmonary vasculature, potentially causing thrombosis and granuloma formation over time 1. Treatment focuses on preventing thrombotic complications, supporting hemodynamics, and managing any acute right ventricular failure.