PE Management

Question 1

Investigations to consider during / after A-E

Answer 1

Confirm / exclude diagnosis:

1. D-dimer - if low 2-level Wells Score
2. CTPA (or V/Q scan if CI)

Other
1. ECG - may show tachycardia, RV strain (T-wave inversion in right precordial (V1) and inferior (II, III, aVF) leads), RBBB, RAD, S1Q3T3

2. CXR - may show wedge infarcts, effusion
3. ECHO - RV dysfunction
4. Troponin - higher mortality if raised

Question 2

What causes might you want to exclude in an unprovoked PE

Answer 2

Malignancy - Hx, Exam, Basic bloods

Antiphospholipid syndrome; antiphospholipid antibodies

Hereditary thrombophilia - consider testing if 1st degree relative also has DVT/PE

Question 3

What is the management algorithm for PE

Answer 3

1. Calculate the 2-level Wells - score to predict likelihood of PE

If score 4 or less - d-dimer - if raised - progress to next

If score 5 or more

• —- give treatment LMWH (i.e. enoxaparin 1mg/kg BD)
• —- CTPA when possible
• —- If CTPA shows PE –> therapeutic anticoagulation for 3-6 months

Question 4

What does the Wells score include

Answer 4

Risk factors:

• Recent surgery or immobility
• Previous VTE or cancer

Symptoms of VTE

• DVT symptoms
• HR
• Haemoptysis

Likelihood of alternative diagnosis

Question 5

What are provoking factors for a PE

Answer 5

Surgery 
Trauma
Significant immobility 
Pregnancy 
Oral oestrogen

Question 6

What are the therapeutic anticoagulant options for PE

Answer 6

LMWH

• usually given initially in larger PE’s until vital signs have normalised, incase the patient deteriorates and thrombolysis is required (DOAC is a relative CI)
• not normally given long-term as the patient will have to give daily-self injections

DOACs

• most commonly used anti-coagulation
• rivaroxaban and apixaban are preferred and have loading doses
• edoxaban and dabigatran do not have loading doses and so are started after 5 days of LMWH

Warfarin

• used where DOACs are CI i.e. renal impairment
• if using warfarin, continue LMWH until had >5 days AND INR 2-3

Question 7

When should you consider thrombolysis and other interventions for PE

Answer 7

High-risk PE –> immediate thrombolysis

• persistent hypotension
• obstructive shock
• cardiac arrest

Intermediate risk PE –> consider heparin infusion initially so thrombolysis can be given more safely if high-risk features develop
- haemodynamically stable but RV dysfunction and/or myocardial necrosis

NB - thrombolysis is followed by an unfractionated heparin infusion

Question 8

What options can be considered if thrombolysis fails or is contraindicated

Answer 8

Surgical embolectomy

Percutaneous catheter directed treatment