Management of Acute Pulmonary Embolism

Question 1

What score is used in helping diagnose a PE?

Answer 1

WELLS score. If score is over 4 then PE is likely and patient requires immediate CT pulmonary angiogram

Question 2

What is the initial management of a patient with an acute PE?

Answer 2

• Anticoagulation without delay then determine if haemodynamically instable. This is if a patients systolic is less an 90mmHg or has dropped by 40+mmHg for more than 15mins in absence of another cause or if patient has undergone cardiac arrest

Question 3

How do you assess cardiac risk in a patient with an acute PE?

Answer 3

-Echo/CT parameters: RV dilatation, RV strain
- Biomarkers: Troponin (most common) or NT-proBNP/BNP

Question 4

What is the management of an acute PE patient who is haemodynamically instable

Answer 4

• Reperfusion therapy which can be via alteplase and haemodynamic support.
• Surgical embolectomy is very rare now as it is high risk

Question 5

What is the management of an acute PE if patient is haemodynamically stable?

Answer 5

Determine whether patient is low or intermediate risk. Patient is intermediate risk if they have one of the following:
- Clinical signs of a severe PE/serious co-morbidity (high PESI)
- Right ventricular dysfunction on ECHO/CT

Question 6

What determines whether a patient is intermediate low risk or intermediate high risk and the management of each?

Answer 6

• Whether they are troponin positive or not
  Intermediate low risk patients - hospitalised.
  Intermediate high risk patients - Hospitalised and monitored, consider reperfusion therapy if deteriorate

Question 7

What is the PESI score?

Answer 7

Pulmonary embolism severity index.

Question 8

What is the management of low risk patients with an acute PE?

Answer 8

• Early discharge with home treatment

Question 9

What are the treatments for right ventricular failure in acute high risk pulmonary embolisms?

Answer 9

• Fluid resuscitation: 500ml bolus over 15-30mils however may cause volume overload and worsen RV strain.
• Vasopressors and inotropes.
• Veno-arterial ECMO (complications with long term use) - extracorporeal membrane oxygenation

Question 10

What are potential indicators for thrombolysis in acute PEs?

Answer 10

• Severe RV dysfunction,
• Severe hypoxemia,
• Patients who appear to be decompensating but aren’t yet hypotensive
• If there is extensive clot burden

Question 11

What is the most common thrombolysis agent used in acute PEs?

Answer 11

Alteplase

Question 12

Explain catheter directed thrombolysis which is used in acute PEs

Answer 12

EKOS system which uses ultrasound waves to irritate the fibrin clot allowing for better penetration of fibrinolytic agents.
This is safer in terms of bleeds as lower doses of fibrinolytic drugs are used so should be considered when bleeding risk is high. However not readily available and takes time to set up