PULMONARY EMBOLISM TREATMENT by Nick Mark MD ONE onepagericu.

com Link to the

most current
Ideally choosing the intervention
@nickmmark version →
is a multi-disciplinary discussion Exclude contraindications. Indications:
(e.g. PERT team) • Massive PE (definite indication)
Diagnosis and Thrombolysis or Systemic • High-risk submassive PE (risk/benefit)
Anticoagulation
risk assessment intervention ICU thrombolysis Std dose alteplase = 100mg IV over 2 hrs
For patients w/ massive or Low dose 0.5 mg/kg (up to 50mg IV)
Physical exam, CT scan, LMWH SC preferable but use
high risk sub-massive PE 2% risk of ICH and 6% risk of other major
POCUS, EKG, labs (VBG, UFH gtt for patients at high risk bleeding with tPA (PIETHO)
lactate, troponin, BNP), & for requiring thrombolysis (it
calculate risk score using an can be turned off promptly) Optimize Catheter Useful in patients who are higher risk for
online calculator hemodynamics thrombolysis. May be superior to anticoag
IR directed lysis alone in intermediate risk PE.
Exam: Tachypnea, JVD, loud P2, S3/4 gallop, diaphoresis, fever, hemoptysis For patients in shock
EKG: Sinus tach, QR in V1, RBBB, TWI V1-4, STE V1-4, S1Q3 3
T
May be useful in patients who fail above
CT: reflux of contrast into IVC, PA > 30 mm, PA > Ao, RV bowing; saddle PE Embolectomy therapies, who have C/I to thrombolysis, or
not associated with increased mortality OR who require surgery for large RA thrombus
POCUS: RV/LV diameter > 0.9, McConnel Sign, septal flattening, dilated Most PE patients do not require IVF; Excess
IVC, decreased TAPSE, clot in transit Optimize preload will worsen RV failure; avoid bolus
PE Mimics: post MI VSD, non-thrombotic PE (fat, air, tumor, septic, foreign Preload unless clear evidence of hypovolemia
matter, etc.), chronic PE, severe PAH

POCUS If low CO, consider use of

Risk prognostication based on scores and clinical features: Augment milrinone or dobutamine;
LOW INTERMEDIATE HIGH risk contractility monitor for hypoTN
Bova score Inotrope
0-2 3-4 5-7 Keep SpO2 > 90% w/ supp O2.
30-day PE-related (6.8%)
Optimize Avoid intubation if possible.
(3.1%) (10%)
mortality oxygenation If intubated; avoid over
PESI class I II III IV V distension (keep Pplat <30);
30-day all cause (<1.6%) (1.7-3.5%) (3.2-7.1%) (4.0-11.5%) (10.0-24.5%) consider low TV (6-8 cc/kg)
mortality
Treat reversible
RV fxn Normal RV RV dysfunction causes
function A4C RV diameter divided by LV diameter >0.9;

PVR
TAPSE < 16mm,
OR AND AND Reduce
Elevated Cardiac Biomarkers PVR Pulmonary FRC
Biomarkers Normal
biomarkers BNP > 90 or N-terminal pro-BNP > 500 vasodilators Lung volume
TnI > 0.4 ng/ml or TnT > 0.1 ng/ml
Inhaled pulmonary Optimize Acidosis will increase PVR.
Massive PE vasodilators (prostacyclins
ventilation Adjust ventilation to correct
Stable Transient Sustained hypoTN or iNO) can decrease PVR
Hemodynamics
hemodynamics hypoTN (>15 min), shock or Maintain
on vasopressors If persistent hypoTN, use a vasopressor that does
afterload not increase PAP: vasopressin, epinephrine, NE

PVR
LMWH UFH pH 7.1
Treatment Thrombolysis For patients with persistent shock despite
pH 7.2
pH 7.4
Embolectomy ECMO thrombolysis; consider VA ECMO
v1.0 (2020-05-03) ECMO PaO2