Pulmonary Embolism

Question 1

What are the classifications of PE?

Answer 1

Massive
Submassive with RV strain
Submassive without RV strain
Subsegmental

Question 2

Definition of massive PE?

Answer 2

Hypotension lasting at least 15 minutes

<90 systolic or decline in40mmHG from baseline

Question 3

Definition of submassive PE?

Answer 3

Transient blood pressure effects, otherwise normotensive

Question 4

What are the signs of RV strain?

Answer 4

RV > LV
CTPA evidence of RV strain
Increased troponin or BNP

Question 5

Treatment for massive PE?

Answer 5

tPA unless contraindicated
Heparin
If no tPA, consider mechanical or open thrombectomy
Consider ECMO and inhaled nitric oxide

Question 6

How is submassive PE with RV strain treated?

Answer 6

Treatment is controversial
If high concern for hemodynamic compromise, may consider tPA
If more on the stable side, may consider only heparin
Consider expert consultation

Question 7

How is submassive PE without RV strain treated?

Answer 7

Assess for risk category and depending on risk may be able to treat and send home, or treat and admit
No tPA, use heparin or DOAC

Question 8

How is subsegmental PE treated?

Answer 8

Consider DVT US

Consider DOAC and home

Question 9

Patient is hypotensive and hypoxemic, what are the first steps of resuscitation?

Answer 9

Oxygen/intubation if needed
IV fluids
Pressors

Question 10

Who gets thrombectomy?

Answer 10

Hemodynamically unstable patients

Question 11

Patient was initially on heparin, but now appears much worse, can thrombolytics be given?

Answer 11

Yes, stop the heparin, give the thrombolytic and then restart the anticoagulation.

Question 12

What score can be used to risk-stratify patient with diagnosed PE, and what are the contributing factors?

Answer 12

PESI score, assesses mortality
Includes:
Age
Gender (male is worse)
Hx of cancer
Hx of chronic cardiopulmonary disease
Heart rate >110
BP <100
Sats <90%
RR>30
Temp <36 degrees
AMS

Question 13

How is DVT location related to PE outcomes?

Answer 13

Proximal DVT plays a significant role in adverse PE-related outcomes

Question 14

At what point during the diagnostic process should anticoagulation be started in patients with high, intermediate, and low suspicion for PE?

Answer 14

High suspicion: should start AC before confirming the diagnosis
Intermediate suspicion: start AC if will take >4 hours to diagnose
Low: start AC if >24 hours to diagnose

Question 15

If you have a hemodynamically unstable patient with a high suspicion for PE, what is the diagnostic and treatment approach?

Answer 15

Bedside assessment with ECHO to look for RV strain and then thrombolytics if positive
Consider empiric thrombolytics if there is no adequate testing available as a life-saving measure when there is high suspicion and the patient is in critical condition. Otherwise, may be appropriate to delay thrombolytics and favor AC until more information and diagnostic certainty can be obtained, based on the patient and their risk factors and preferences.

Question 16

Diagnosis is made and possible interventions are being considered including thrombectomy vs thrombolysis. Should AC be started in the meantime?

Answer 16

Yes, do not delay AC while other interventions are being planned and considered.

Question 17

How should fluid resuscitation be approached in hypotensive patients with known PE?

Answer 17

Limit fluid to around 500cc unless clearly volume depleted.
Excessive fluid can overstretch the RV causing RV ischemia, and worsening RV failure.
Give the initial fluid bolus, and then move on to pressors if no response.

Question 18

What are risk factors for bleeding on AC?

Answer 18

Age >65 (over 75 gets 2 points)
Cancer (metastasis gets 2 points)
Kidney/liver failure
Thrombocytopenia
Hx of bleeding
Previous stroke
Diabetes
Frequent falls
Alcohol use
Recent surgery (10 days)
Anemia

Question 19

What AC is preferred in liver disease and why?

Answer 19

Lovenox
DOACS contraindicated in elevated INR from liver disease
Can’t use warfarin due to inability to use INR to monitor

Question 20

What AC is preferred in cancer patients?

Answer 20

Lovenox or Xa inhibitors

Question 21

What AC is preferred in renal failure patients?

Answer 21

Warfarin as lovenox is contraindicated and DOACS would need renal adjustment

Question 22

What should be done with a cardiac patient on antiplatelets that now needs AC?

Answer 22

Avoid the antiplatelet if possible while on AC due to risk of bleeding

Question 23

What AC is preferred in Hx of GI bleeding?

Answer 23

Warfarin or Eliquis
Xarelto is worse for GI bleeding

Question 24

Which AC is best when thrombolysis is being used or considered?

Answer 24

Heparin infusion

Question 25

Which AC is preferred in pregnancy?

Answer 25

Lovenox as others have possibility of crossing the placenta

Question 26

What are absolute contraindications to thrombolytics?

Answer 26

Previous brain bleed
Known brain vascular malformation
Known intracranial malignancy
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding (not menses)
Significant head or face trauma in the last 3 months

Question 27

Which vasopressor is first line and why?

Answer 27

Norepinephrine is generally first because it is less likely to cause tachycardia which can worsen hypotension, but dopamine and epinephrine can also be used.

Question 28

Are menses, epistaxis, or minor hemoptysis contraindications to anticoagulation?

Answer 28

No, but should be monitored.
Active bleeding can be a contraindication to thrombolysis, though.

Question 29

Why might lovenox be preferred to heparin for initial AC?

Answer 29

Guarantees therapeutic levels within 4 hours

Question 30

What is the treatment for stable patients that have contraindications for AC due to high bleeding risk?

Answer 30

IVC filter

Question 31

Patient has a PE, but appears well, is hemodynamically stable, and has no residual DVT. AC is contraindicated. Do they need anything else?

Answer 31

IVC filter should still be considered even if the clot burden is low and there is no residual DVT.

Question 32

How long should patients initially be anticoagulated?

Answer 32

At least 3 months

Question 33

Should small subsegmental PE’s receive AC?

Answer 33

Controversial
UpToDate favors AC
Can consider not treating based on the clinical scenario including no DVT in arms or legs, normal vitals, small clot burden, limited risk factors for clots, normal d-dimer, good cardiorespiratory reserve, or patient preference
2 week follow up US of the legs should be done to look for a proximal thrombus