A Case of Rapid Cardiopulmonary Collapse in a Patient with Advanced Metastatic Cancer

Case at a Glance

A 34-year-old female with advanced cancer and extensive lung metastases, managed at home with supplemental oxygen, experienced a sudden and rapid deterioration. Despite initial reports of feeling well, she suffered a syncopal episode followed by severe dyspnea, pain, and distress, culminating in cardiac arrest. This case illustrates the terminal events of hypoxic respiratory failure and the challenges of pre-hospital assessment in a patient with circulatory collapse.

Patient's Story

The patient was a 34-year-old female with a recent diagnosis of advanced metastatic cancer (primary site not specified). In the weeks prior to her death, a CT scan had confirmed significant progression of pulmonary metastases, with multiple nodules growing over 1cm in a 10-day period. It was estimated that approximately 30% of her lung parenchyma was compromised by tumor growth. An ECG during this period had also noted a non-specific abnormality of the left ventricle. Due to progressive dyspnea and hypoxemia, with a resting SpO2 of 88% on room air during an office visit, she was started on continuous home oxygen at 4 L/min one week before her death. While on supplemental oxygen, her saturation levels reportedly fluctuated between 89% and 94%. She was also on a regimen of high-dose opioids for cancer-related pain.

Initial Assessment

On the morning of her death, the patient initially reported feeling 'fine' to her husband. Shortly thereafter, while downstairs, she experienced an abrupt syncopal episode, collapsing and remaining unresponsive with her eyes open for several minutes. Upon regaining consciousness, she was in acute distress, complaining of severe dyspnea ('I can't breathe'), agonizing pain, and immediately asked for emergency services to be called. She became incontinent of bowel and expressed distress over this.

The Diagnostic Journey

Emergency Medical Services (EMS) arrived to find the patient in extremis. A finger-probe pulse oximeter initially showed a reading of 100%, a finding likely erroneous due to poor peripheral perfusion in a state of shock, combined with the administration of supplemental oxygen. The patient was visibly distressed, complained of significant pain when her back was supported, and was too weak to cooperate with a blood pressure measurement. She rapidly lost consciousness for a second and final time, at which point her husband noted her lips were turning blue (perioral cyanosis). An EMT observed an involuntary lip movement after she lost consciousness.

Given the profound respiratory compromise, EMS suspected fluid around the lungs (pleural effusion) and proceeded with field intubation and advanced cardiac life support protocols. En route to the hospital, she received at least one injection of a clear medication, likely a vasopressor such as epinephrine. Upon arrival at the Emergency Department (ED), she was in cardiac arrest with a mechanical device performing chest compressions. The ED physician conveyed a grave prognosis to the family, stating that her vital signs were incompatible with survival.

Final Diagnosis

The patient's official cause of death was recorded as Acute Hypoxic Respiratory Failure secondary to extensive pulmonary metastatic disease. The rapid deterioration was precipitated by the high tumor burden, which severely compromised gas exchange. This baseline respiratory failure was likely complicated by bilateral pleural effusions (as suspected by EMS), leading to compressive atelectasis and further worsening her hypoxia. A sudden, massive pulmonary embolism, a common complication in advanced cancer (a hypercoagulable state), cannot be ruled out as the terminal event that caused the abrupt and irreversible cardiopulmonary collapse.

Treatment Plan

The patient's chronic management included palliative home oxygen therapy and analgesia with opioids. The acute event was managed with pre-hospital advanced life support, including endotracheal intubation and resuscitative medications. In the Emergency Department, resuscitation was continued with mechanical chest compressions and full ACLS protocols until it was determined to be futile.

Outcome and Follow-up

Despite aggressive resuscitation efforts, the patient could not be stabilized and was pronounced dead in the emergency department. An autopsy was not performed. This case highlights the potential for sudden and catastrophic decline in patients with end-stage cancer, even when they appear relatively stable. The discrepancy between the patient's severe subjective dyspnea and the initial 100% SpO2 reading underscores that in states of low perfusion or shock, pulse oximetry can be unreliable and clinical signs (distress, cyanosis, altered mental status) are paramount. The agonal phenomena (lip movement) and open eyes during unconsciousness are non-specific neurological signs seen in the dying process and do not indicate awareness or pain. The patient's pain on being touched could have stemmed from the extreme sensation of air hunger ('suffocation') or potential tumor infiltration of the pleura or chest wall. Ultimately, her rapid decline from a state of compensated respiratory failure to irreversible cardiopulmonary arrest was a direct and tragic consequence of her advanced malignant disease.