Description
A 39-year-old morbidly obese man with a medical history of tobacco abuse and paroxysmal atrial fibrillation (Afib) on rivaroxaban presented to the emergency department with acute onset of shortness of breath and severe pleuritic chest pain. His vital signs were significant for blood pressure of 100/60 mm Hg, heart rate of 110 per minute, respiratory rate of 30 per minute and oxygen saturation of 80% on a non-rebreather mask. Physical examination was unremarkable, except for increased work of breathing. Arterial blood gas (ABG) showed pH 7.49, PaCO2 30 mm Hg and PaO2 86 mm Hg. Laboratory tests were significant for elevated troponin at 2.35 ng/mL and B-type natriuretic peptide at 309 pg/mL. ECG showed sinus tachycardia with new onset incomplete right bundle block and T-wave inversion in the right precordial and the inferior leads (figure 1A). A chest CT revealed extensive bilateral pulmonary embolism (PE), involving both main pulmonary arteries and suspected mass in the right...
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