Abstract
Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient’s disease process and treatment.
Keywords
Introduction
Severe acute respiratory syndrome coronavirus 2 is a novel coronavirus that was identified in late 2019 and causes coronavirus disease 2019 (COVID-19). Infection with COVID-19 is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Patients with CAC are at increased risk for venous thromboembolism (VTE) due to elevated levels of factor VIII and fibrinogen as well as inflammation-associated hyperviscosity of blood. 1 Trauma patients with COVID-19 often have all of the components of Virchow’s triad of hypercoagulability including endothelial injury, stasis, and a hypercoagulable state. This can lead to VTE including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thrombolytic agents can be directly infused into the pulmonary artery via pulmonary artery thrombolysis catheters, which can be done without increased risk of bleeding in comparison to systemic therapy. 2 We report a case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures status post-retrograde intramedullary nailing who then developed massive bilateral pulmonary emboli.
Case Report
This is the case of a 26-year-old female with no past medical history who presented after a motorcycle collision and was found to have open left middle transverse and distal comminuted femur fractures. Computed tomography scan with IV contrast did not show any primary pulmonary artery thrombosis from trauma. Deep vein thrombosis prophylaxis was initially held on admission. She was placed in traction then underwent retrograde intramedullary nailing the following day. Post-operatively, she required non-rebreather mask oxygen therapy and was hypotensive. Thromboelastography (TEG) showed a slightly decreased R time, and other values were normal. Computed tomography angiogram scan showed extensive thrombus within the main pulmonary arteries bilaterally extending into all branches with evidence of right heart strain with inferior vena caval contrast reflux (Figure 1). The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement. She developed cardiogenic shock with severely decreased left and right ventricle function and was placed on left femoral venoarterial extracorporeal membrane oxygenation (ECMO). Her vasopressor requirements quickly improved. Repeat echocardiograms showed improvement in cardiac function, and ECMO was discontinued 5 days later. She recovered and was discharged with a good long-term prognosis. Axial CT showing right heart strain with inferior vena caval contrast reflux from bilateral pulmonary emboli.
Discussion
Some patients with COVID-19 have increased plasma levels of factor VIII, von Willebrand factor, and fibrinogen which can contribute to DVT formation and PE. In a study examining the TEG results of 24 intubated COVID-19 patients, findings were decreased R times indicating a shorter time to clot formation and increased K angle values demonstrating increased velocity of clot formation. Maximal amplitude values of the clot were increased meaning amplified clot firmness, and percentage decrease of clot amplitude at 30 minutes (Lys-30) was decreased showing reduced clot breakdown. 1 This severe inflammatory and hypercoagulable state can contribute to the formation of DVT and PE, and similar trauma patients in the future with recent COVID-19 infection should be placed on DVT chemical prophylaxis as soon as possible. Pulmonary artery catheter-directed thrombolysis can have better efficacy in reversing right ventricular dilatation without increased risk of bleeding in comparison to systemic heparin therapy. 2 Patients with extreme cardiopulmonary collapse should be considered for placement on ECMO. 3 Although COVID-19 is considered primarily to be a nonsurgical disease, infection can affect trauma and surgical patients, placing surgeons in an important role both as operators and intensivists. 4 Surgeons can be versatile and provide successful care for both surgical and medical critically ill patients. 5
Conclusions
This case demonstrates a presentation of CAC in a young trauma patient without comorbidities. Life-threatening concurrent COVID-19 and PE present a challenge which can require treatment with pulmonary artery catheter-directed thrombolysis and ECMO. Surgeons providing trauma and critical care can provide successful care for patients with CAC.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.