Successful management of life-threatening acute pulmonary embolism during anesthesia induction for comminuted intertrochanteric fracture surgery: a case report

Background: Acute perioperative pulmonary embolism (APE) is a life-threatening complication that demands immediate clinical recognition and intervention. This report describes the emergency management and successful recovery of an 85-year-old female who experienced sudden, catastrophic cardiovascular collapse due to APE immediately following general anesthesia induction for orthopedic surgery. Methods: A retrospective analysis was conducted on an 85-year-old female admitted with an un-stabilized comminuted intertrochanteric fracture of the right femur. The study chronologically details the clinical presentation during an 11-day preoperative immobilization window, the intraoperative crisis management utilizing real-time bedside diagnostics, and the subsequent multidisciplinary rescue protocol involving targeted pharmacological thrombolysis and intensive care stabilization. Results: Initial screening revealed a profound hypercoagulable state. Following anesthesia induction, the patient experienced sudden cardiovascular collapse and new-onset atrial fibrillation with complete right bundle branch block. Bedside echocardiography rapidly confirmed right ventricular enlargement, indicating massive APE and obstructive shock. An emergency low-dose systemic thrombolysis regimen (50 mg alteplase) was successfully executed. Post-thrombolysis evaluations in the intensive care unit noted expected consumptive coagulopathy and transient anemia, managed via supportive care and blood transfusion. Computed tomography pulmonary angiography confirmed bi-lobed pulmonary embolism. Under multidisciplinary optimization and transitioned rivaroxaban therapy, the patient achieved complete clinical recovery at 1-year follow-up. Conclusions: This case underscores the importance of intraoperative point-of-care ultrasound and electrocardiographic monitoring in fragile geriatric patients undergoing extended preoperative delays. When mechanical options are unavailable, low-dose systemic thrombolysis can serve as a viable rescue pathway to reverse acute obstructive shock, though its wider generalizability requires cautious interpretation.