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ED Mx of pulmonary embolism (PE)

Mx of suspected PE in the stable patient

Mx of impending or actual cardiac arrest in patients with presumed PE

  • CPR and ACLS resuscitation has limited or no utility as the obstructed pulmonary circuit prevents blood flow to the systemic and cerebral circulation resulting in rapidly progressive severe hypotension and EMD/PEA cardiac arrest.
  • avoid intubation if possible as this is likely to result in exacerbation of haemodynamic compromise and cause cardiac arrest
  • timely cardiopulmonary bypass with ECMO or emergency thoracotomy with pulmonary embolectomy are the only likely life-saving options once it is too late for thrombolysis to be effective.

Mx of the unstable patient with presumed PE

  • patients who collapse with massive PE tend to die within 2hrs of onset unless aggressive Mx is instituted
  • high flow oxygen
  • move to a resuscitation cubicle
  • IV access, take bloods for FBE, U&E, clotting, ABG's
  • cardiac monitor
  • rapid confirmation if possible via either echo (preferably TOE) or CTPA
  • early anticoagulation to reduce further clot forming (but this does not reduce existing clot!) such as:
    • unfractionated heparin 80 units/kg loading dose IV, followed by 18 units/kg/hr IV infusion, adjusted according to APTT.
      • preferred in high risk PEs where thrombolysis may be needed as it can be ceased in the event of major bleeding
  • early thrombolysis for any patient who does not have overwhelming C/I and who has evidence of massive PE with either:
    • severe hypoxia
    • ongoing hypotension
    • right heart failure
    • or, controversially, consider in sub-massive PE esp. in those under 65yrs where bleeding risk is much lower, if either:
      • an episode of hypotension - such an episode in these patients suggests reserves are critical and death may be imminent!
      • evidence of right heart strain
      • massive ileo-femoral thrombosis
  • thrombolysis dose if appropriate, preferably after discussion with respiratory:
  • cautious iv fluid loading, although this may worsen the outcome
  • admit to a hospital preferably with access to ICU and ECMO if this would be considered in the patient - ie. not a palliative care patient.
  • APTT should be checked after 4 to 6 hours and the dose of heparin adjusted if APTT is not in the therapeutic range. When the APTT is in the therapeutic range, the dose should be reviewed daily.
  • warfarin should be started within 48 hours using the regimen for deep venous thrombosis (DVT)

Mx of the stable patient with newly diagnosed PE

  • iv access, bloods for prothrombotic screen, U&E, FBE, baseline clotting
  • if significant hypoxia or any episode of hypotension, see above under Mx of unstable patient.
  • 12 lead ECG
  • CXR if not already performed
  • consider:
    • troponin - elevated troponin levels in pts with PE suggests RV strain and should probably be considered as “unstable”
    • echocardiogram to assess degree of RV strain - significant RV strain should also be considered “unstable”
    • evidence of RV dysfunction is an indication for hospital admission
    • evidence of RV dysfunction with raised troponin indicating injury is usually an indication for ICU admission &/or thrombolysis
  • these patients are usually admitted (often under the respiratory unit rather than general medicine) for observation and commencement of anticoagulation
    • early anticoagulation with either heparin or enoxaparin reduces overall mortality from 30% to below 10%.
    • initial enoxaparin (preferred over heparin as lower bleeding rates and HIT for low risk PEs where thrombolysis is unlikely to be needed), then DOACs
  • outpatient Mx:
    • may be suitable with DOACs / NOACs 1) if NO high risk factors present such as:
      • age ≥ 70;
      • any one of: active cancer/ heart failure/ chronic lung disease/ cerebrovascular disease;
      • renal or hepatic disease
      • thrombocytopenia
      • pregnancy
      • high risk of bleeding - consider using the HAS_BLED or the Outpatient Bleeding Risk Index
      • large or massive PE:
        • any one of: pulse ≥ 110; SBP < 100 mmHg; altered mental status; SaO2 < 90%;
        • raised troponin indicating RV myocardial damage
        • echocardiographic or CTPA evidence of RV dysfunction
      • compliance issues (missing one dose of DOAC can be problematic)
      • low HOPPE-SAO2 score:
      • low PESI score < 86:
    • ensure the patient agrees with the plan and discuss with the patient the need to return to the ED for worsening shortness of breath (at rest or with exertion), syncope, worsening chest pain, or any other concern.
      • rivaroxaban - 15mg bd for 21 days then 20mg once daily - write a script for BOTH to ensure patient does not cease after initial bd dose runs out
      • edoxaban - 60mg once daily but needs initial parenteral anticoagulation 5-10 days
      • apixaban - but needs long term bd dosing with compliance issues - 10mg bd for 7 days then 5mg bd
      • dabigatran - needs long term bd dosing with compliance issues - 150mg bd, and needs initial parenteral anticoagulation 5-10 days
  • patients not suitable for outpatient Mx should be admitted to hospital for parenteral anticoagulation - usually under the respiratory unit

target INR on warfarin Rx

usual duration of anticoagulation Rx:

  • patients with irreversible and clinically apparent hyper-coagulable states, such as neoplastic disease, or, chronic thromboembolic pulmonary hypertension2), then life long Rx.
  • patients with a non-transient risk factor, then 12 months Rx.
  • patients with a transient risk factor, then 6 months Rx.

Mx of new PE in the adequately anticoagulated patient

  • patients who develop new PE's whilst on adequate anticoagulation should be considered for IVC filter insertion to prevent further emboli
  • such patients tend to have a higher risk of underlying risk factors such as occult neoplasms and this should be considered in their work up.
pe_mx.txt · Last modified: 2022/04/26 23:45 by gary1

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