Management Of Acute PE

Question 1

Learn the NICE diagram for management of acute PE

Answer 1

Go to notes

Question 2

Describe how you would risk stratify PE patients

Answer 2

• are they haemodynamically stable? (Yes = high risk)
• if PESI class III-IV (86-125 points) troponin positive + RV dysfunction = intermediate high risk
• if PESI class III-IV with/without RV dysfunction but troponin negative = intermediate low risk
• neither of these symptoms/signs = low risk

Question 3

When would you commence anticoagulation treatment in patients with PE?

Answer 3

As soon as you clinically suspect that the patient is having a PE (unless contraindicated)

Question 4

What defines haemodynamic instability?

Answer 4

• systolic BP less than 90mmHg
• drop of >40mmHg for more than 15 mins in absence of other cause
• cardiac arrest

Question 5

Describe how to assess cardiac risk of patients

Answer 5

Echo/CT parameters:
- RV dilation
- RV strain
- increased TRPG (tricuspid regurgitation pressure gradient)
- hypokinesis RV wall

Biomarkers:
- troponin
- BNP
- NT-proBNP

Question 6

Describe the parameters in the PESI score

Answer 6

• age
• male sex (10)
• cancer (30)
• chronic HF (10)
• chronic pulmonary disease (10)
• pulse rate >110bpm (20)
• systolic BP <100 mmHg (30)
• resp rate >30 (20)
• temp <36 degrees (20)
• altered mental status (60)
• sats <90% (20)

Question 7

How would you manage a patient with suspected PE with haemodynamic instability?

Answer 7

• bedside echo to confirm RV dysfunction
• if positive take for CT pulmonary angiography
• if positive then high risk and commence treatment to manage the right heart
• volume optimisation (if low venous pressure) = saline bolus
• vasopressors + ionotropes = norepinephrine, dobutamine
• mechanical circulatory support = ECMO

Question 8

What is the reperfusion therapy options for PE patients?

Answer 8

• systemic thrombolysis
• catheter directed thrombolysis
• surgical approach

Question 9

When is thrombolysis indicated?

Answer 9

• high risk PE
• patients with severe RV dysfunction due to PE
• presence of severe hypoxemia (esp with concurrent CV illness)
• decompensation but not yet hypotensive
• extensive clot burden

Question 10

List the effects of thrombolysis

Answer 10

• improvement of pulmonary vascular resistance
• improved RV function
• improved pulmonary pressure + perfusion

Question 11

What agents are used in thrombolysis?

Answer 11

• alteplase
• streptokinase
• urokinase

Question 12

Why do we not give thrombolysis treatment to intermediate or low risk PE patients?

Answer 12

it may improve RV function but it can increase the risk substantially of an intra-cranial bleed

Question 13

What are the benefits and disadvantages of catheter directed thrombolysis?

Answer 13

Benefits:
- safer in terms of bleeds
- lower doses used
- consider when bleeding risk is high
- can allow direct clot retrieval

Disadvantages:
- not readily available
- takes time to set up