Management of acute PE

Question 1

Give the overview of PE management

Answer 1

•Patient has an acute PE, risk stratify then according to risk: 
 - Thrombolyse if high risk 
 - Consider thrombolysis if med risk 
 - consider d/c if low risk 
•Then give LMWH or DOAC 
•Then risk stratify again 
- consider long term anticoagulation 
 - CTEPH screening 
 - Consider cancer screening

Question 2

What is the score for PE?

Answer 2

Wells

Question 3

What should you do if wells score is>4?

Answer 3

• Immediate CTPA or interim therapeutic anticoagulation while awaiting CTPA
• If CTPA is positive then diagnose PE and offer or continue anticoagulant
• If negative think about alternative diagnoses and stop anticoagulation or if you still suspect a PE then consider an ultrasound scan of the proximal leg vein

Question 4

What should you do if the wells score is<4?

Answer 4

• Await quantitive D-dimer
• If negative, consider other diagnoses
• If positive then CTPA

Question 5

How do you differentiate a low risk PE from an intermediate or high risk PE?

Answer 5

• Look for clinical signs of PE severity, or serious comorbidity
• Is there any evidence of RV dysfunction on TTE or CTPA?
• If neither of these apply then they are likely low risk, if either are present then carry out a troponin test, if negative then intermediate low but if positive with RV dysfunction then intermediate-high risk
• High risk = haemodynamic instability

Question 6

When confirmation of a diagnosis of PE is expected to be delayed bu more than one hour what should you do?

Answer 6

Give an interim dose of anticoagulant

Question 7

What is haemodynamic instability?

Answer 7

• Systolic BP is less than 90mmHg or drop of >40mmHg for more than 15 minutes in the absence of other causes e.g. sepsis
• Cardiac arrest

Question 8

How can you assess cardiac risk?

Answer 8

•Echo/CT parameters:

• RV dilation
• RV strain
• Increased TRPG
• Hypokinesis RV wall

•Biomarkers:

• troponin
• BNP
• NT-proBNP

Question 9

What is the score for the severity of PE?

Answer 9

PESI

Question 10

What is the management of those with haemodynamic instability?

Answer 10

• Reperfusion treatment

* Haemodynamic support

Question 11

What is the treatment of right ventricular failure in acute high risk pulmonary embolism?

Answer 11

• Cautious volume loading: saline
• Norepinephrine
• Dobutamine
• Veno-arterial ECMO

Question 12

What is repercussion therapy?

Answer 12

• Systemic thrombolysis
• Catheter directed thrombolysis
• Surgical approach

Question 13

What are the indications for systemic thrmbolysis?

Answer 13

•High risk (massive) PE
•Potential indications:
- patients with severe right ventricular dysfunction due to PE
- presence of severe hypoxaemia
- patients with acute PE who appear to be decompensation but not yet hypotensive
- extensive clot burden

Question 14

What does thrombolysis do?

Answer 14

• Improves pulmonary vascular resistance
• Improved RV function
• Improves pulmonary pressures and perfusion

Question 15

Describe the management of submassive PE

Answer 15

• No clear strategy other than monitor closely
• Rescue perfusion is available
• case by case discussion

Question 16

What are the advantages of catheter directed thrombolysis?

Answer 16

• Safer in terms of bleed
• Lower doses used
• consider when bleeding risk is high
• Can allow direct clot retrieval