Pulmonary Embolism Flashcards
What are the classifications of PE?
Massive
Submassive with RV strain
Submassive without RV strain
Subsegmental
Definition of massive PE?
Hypotension lasting at least 15 minutes
<90 systolic or decline in40mmHG from baseline
Definition of submassive PE?
Transient blood pressure effects, otherwise normotensive
What are the signs of RV strain?
RV > LV
CTPA evidence of RV strain
Increased troponin or BNP
Treatment for massive PE?
tPA unless contraindicated
Heparin
If no tPA, consider mechanical or open thrombectomy
Consider ECMO and inhaled nitric oxide
How is submassive PE with RV strain treated?
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
How is submassive PE without RV strain treated?
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
How is subsegmental PE treated?
Consider DVT US
Consider DOAC and home
Patient is hypotensive and hypoxemic, what are the first steps of resuscitation?
Oxygen/intubation if needed
IV fluids
Pressors
Who gets thrombectomy?
Hemodynamically unstable patients
Patient was initially on heparin, but now appears much worse, can thrombolytics be given?
Yes, stop the heparin, give the thrombolytic and then restart the anticoagulation.
What score can be used to risk-stratify patient with diagnosed PE, and what are the contributing factors?
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
How is DVT location related to PE outcomes?
Proximal DVT plays a significant role in adverse PE-related outcomes
At what point during the diagnostic process should anticoagulation be started in patients with high, intermediate, and low suspicion for PE?
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
If you have a hemodynamically unstable patient with a high suspicion for PE, what is the diagnostic and treatment approach?
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.
Diagnosis is made and possible interventions are being considered including thrombectomy vs thrombolysis. Should AC be started in the meantime?
Yes, do not delay AC while other interventions are being planned and considered.
How should fluid resuscitation be approached in hypotensive patients with known PE?
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.
What are risk factors for bleeding on AC?
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
What AC is preferred in liver disease and why?
Lovenox
DOACS contraindicated in elevated INR from liver disease
Can’t use warfarin due to inability to use INR to monitor
What AC is preferred in cancer patients?
Lovenox or Xa inhibitors
What AC is preferred in renal failure patients?
Warfarin as lovenox is contraindicated and DOACS would need renal adjustment
What should be done with a cardiac patient on antiplatelets that now needs AC?
Avoid the antiplatelet if possible while on AC due to risk of bleeding
What AC is preferred in Hx of GI bleeding?
Warfarin or Eliquis
Xarelto is worse for GI bleeding
Which AC is best when thrombolysis is being used or considered?
Heparin infusion
Which AC is preferred in pregnancy?
Lovenox as others have possibility of crossing the placenta
What are absolute contraindications to thrombolytics?
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
Which vasopressor is first line and why?
Norepinephrine is generally first because it is less likely to cause tachycardia which can worsen hypotension, but dopamine and epinephrine can also be used.
Are menses, epistaxis, or minor hemoptysis contraindications to anticoagulation?
No, but should be monitored.
Active bleeding can be a contraindication to thrombolysis, though.
Why might lovenox be preferred to heparin for initial AC?
Guarantees therapeutic levels within 4 hours
What is the treatment for stable patients that have contraindications for AC due to high bleeding risk?
IVC filter
Patient has a PE, but appears well, is hemodynamically stable, and has no residual DVT. AC is contraindicated. Do they need anything else?
IVC filter should still be considered even if the clot burden is low and there is no residual DVT.
How long should patients initially be anticoagulated?
At least 3 months
Should small subsegmental PE’s receive AC?
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
