COVID-19 ARDS and Pulmonary Embolism - A Case Report of Nebulized Nitroglycerin and Systemic Thrombolysis for Right Ventricular Failure

Karfunkle, Benjamin; Gill, Joseph; Shirey, Setphanie; Gordon, Richard

Background: Acute respiratory compromise due to complications of COVID-19, such as acute respiratory distress syndrome (ARDS) or thromboembolic disease, is a complex syndrome with unique challenges in treatment. Management often requires time and intensive care through a multi-professional, multi-specialty approach. Initial management is particularly challenging within the limited resource environment of the emergency department (ED). The emergency physician's toolbox of treatments with reasonably rapid onset remains limited to respiratory support, prone positioning, steroids, and anticoagulation. Case Report: Here we present a case of a patient with COVID-19 complicated by ARDS and bilateral pulmonary emboli with severe right ventricular dysfunction and systemic hypotension treated with nebulized nitroglycerin and systemic thrombolytic therapy in the ED. Serial evaluation of right ventricular function using point of care ultrasound over the next two hours showed improvement of function with both agents as well as improvement in the patient's respiratory rate and work of breathing. Why Should an Emergency Physician Be Aware of This?: This case describes a novel use of a widely available medication for patients suffering from COVID-19 induced right ventricular dysfunction. Nebulized nitroglycerin may be an option to improve right ventricular function when other inhaled pulmonary vasodilators are not available in the initial ED setting.