Admission Checklist

ABC's

• Assess for high-risk PE (hypotension), evidence of RV strain, clot in transit - have crash cart and pads nearby
• If hypoxic, supplement for >90%; avoid mechanical ventilation if possible due to risk of hemodynamic collapse
• Involve a PE response team (PERT) for consideration of thrombectomy vs lytics as needed
• Consider VA-ECMO if hemodynamically unstable

Triage

• PESI score once PE diagnosed
• Troponin and NT-proBNP
• Imaging -  RV/LV >0.9, McConnell’s, septum bulging, TR

Chart Check

• Prior VTE episodes
• Current AC use, fill history
• Recent surgeries
• Cardiac, pulmonary disease, cancer
• Contraindications to thrombolytics
• Baseline coagulation studies

Can't Miss

• High-risk or Intermediate-high risk PE
• A contra-indication for lytics

Admission Orders

• Continuous telemetry and pulse oximetry
• Troponin and NT-proBNP if not already done
• Coags, Fibrinogen, T+S (in case tPA is given to know baseline and in case of bleeding episode)
• VBG; venous lactate - trend as needed
• Lower extremity dopplers in appropriate context

Initial Treatment

• Oxygen as needed
• Fluid - a 500cc bolus, careful to not overload the RV
• Anticoagulation - LMWH generally preferred over UFH except in cases where the patient is unstable or has CKD/ESRD
• Thrombolytics if unstable and no contraindications
• Consider catheter-directed intervention or thrombectomy if available as well as early VA-ECMO for unstable patients

Absolute Contraindications for tPA

• Active serious bleed
• Any history of hemorrhagic CVA
• Ischemic CVA in last 3 monhs
• Known AVM
• Recent brain/spinal surgery
• Head trauma with fracture or brain injury in last 3 weeks
• Suspected or known aortic dissection

Relative Contraindications for tPA (not exhaustive):

• CNS tumor
• Major non-CNS surgery in last 2-3 weeks
• Ischemic CVA > 3 months ago
• plt <100, INR >1.7, fibrinogen <150
• Use of oral AC in last 48 hours
• GI bleed in last month
• BP >180/110
• Age >75 yo
• Advanced cirrhosis (coagulopathy)

HPI Intake

• Symptoms: SOB, chest pain (pleuritic?), syncope, palpitations, hemoptysis
• Onset: When did symptoms start? Sudden vs gradual? Getting better or worse?
• Associated Sx: Leg pain/swelling, fever, cough
• Risk Factors:
  • Recent immobility: Surgery, hospitalization, long travel (>4 hours)
  • Cancer history: Active malignancy, recent chemo
  • Estrogen exposure: OCPs, HRT, pregnancy, postpartum
  • Recent trauma/surgery: Orthopedic, abdominal, pelvic
  • Chronic illnesses: CHF, CKD, autoimmune disease
  • Family history: Clotting disorders, recurrent VTE in family
• Baseline Functional Status: Exercise tolerance, need for O2
• Prior Episodes: History of VTE, anticoagulation history
• Bleeding Risk: Recent bleeding, GI (ulcer, varices, diverticulosis), intracranial disease (stroke, aneusrysm), trauma
• Medications: Anticoagulants (missed doses, taking correctly), hormonal therapy, NSAIDs
• Comorbidities:
  • Cancer - increases risk of clotting
  • Heart failure, CAD, AFib - all increase risk of hemodynamic collapse and may already be on DAPT
  • COPD/Asthma, pHTN - baseline lung disease can impact oxygenation and increase risk of RV failure
  • CKD - can impact AC choices and leads to increased bleeding risk given uremic platelet dysfunction
  • Autoimmune - lupus and APLS increases risk of clotting; Warfarin is preferred treatment in APLS

To Note on Exam

General

• Tachypnea (RR>20), tachycardia (HR>100), hypoxia
• Mental status changes
• Respiratory distress

Cardiac

• JVD suggesting right heart strain
• Kussmaul Sign (elevated JVP with inspiration)
• RV heave
• Loud P2
• S4 gallop
• Systolic murmur at left sternal border

Pulmonary

• Tachypnea (sensitivity 80%)
• Rales
• Decreased breath sounds
• Pleural rub

Extremities

• Signs of DVT (in ~30-50% of cases)
  • Unilateral leg swelling/pain (sensitivity ~11%, specificity ~97%)
  • Palpable cord
  • Homan's sign (pain in calf with dorsiflexion; low sensitivity/specificity)
• Peripheral Edema (possible sign of RV failure)
• Petechiae, purpura (suggestive of coagulopathy or thrombocytopenia)

Etiology/Differential

Thrombotic Etiologies

• Provoked - surgery, trauma, immobility among most common
• Unprovoked - no clear transient cause

PE Mimics

• Cardiovascular - ACS, aortic dissection, ADHF, pericarditis or tamponade
• Pulmonary - pneumonia, (tension) pneumothorax, pleuritis, bronchitis
• Gastrointestinal - GERD, cholecystitis
• Musculoskeletal - costochondritis
• Psychogenic - anxiety/panic disorder

DDx for Elevated D-Dimer‍

• Arterial thrombus (MI, stroke, acute limb ischemia)
• Dissection
• DIC
• Malignancy
• Infection/sepsis
• ESLD,
• Renal disease
• RA, IBD
• Increased age
• Trauma
• Surgery
• Pregnancy

If You Remember Nothing Else

PE management hinges on accurate risk stratification using hemodynamics, RV function, and biomarkers. Start anticoagulation immediately unless contraindicated. For high-risk PE, consider catheter-based intervention or systemic thrombolysis as well as VA-ECMO. Intermediate-risk patients need close monitoring as 5-10% may deteriorate. Consider catheter intervention for intermediate-high risk patients not improving after 24-48h of anticoagulation. Low-risk patients can often be managed with anticoagulation alone. Avoid mechanical ventilation if possible due to risk of hemodynamic collapse. The treatment landscape is rapidly evolving with increasing use of catheter-based interventions over systemic thrombolysis.

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