# Pulmonary Embolism
-- High Risk / Massive - cardiac arrest or SBP <90 not due to hypovolemia, arrhythmia / PESI IV+
-- Intermediate Risk / Submassive - right heart strain (NT-proBNP >500, echo features of overload or dysfunction) w/o hypotension; Intermediate-high if both trop and RV strain; Intermediate-low if trop OR RV strain but not both / PESI III
-- Low Risk / Nonmassive - no right heart strain or hypotension; low-risk PESI I-II
-- ABCs: massive PE (hypotension), evidence of RV strain, saddle embolism, clot in transit - call the PE response team (PERT), consider thrombectomy vs lytics; if massive PE, have crash cart and pads nearby
-- Chart Check: calculate PESI, look for previous VTE, malignancy, recent surgery, AC use
-- Can't Miss: massive PE or RV strain
-- Admission Orders: continuous tele, CBC with diff, trop, NT-proBNP, coags, fibrinogen (in case push tPA for baseline), dimer, echo, LE dopplers, VBG, lactate, coags, type and screen
-- Initial Treatment to Consider: oxygen, fluid, analgesia, UFH vs lovenox
-- Absolute Contraindications for tPA: hemorrhagic CVA, ischemic CVA in last 3 monhs, known AVM, recent brain/spinal surgery, recnet heas trauma with fracture or brain injury in last 3 weeks, serious active bleed
-- Relative Contraindications for tPA: (not exhaustive) CNS tumor, major non-CNS surgery in last 2-3 weeks, plt <100, INR >1.7, fibrinogen <150, use of oral AC, BP >180/110, age >75 yo, advanced cirrhosis
-- History: *** AC, risk factors (previous DVT/PE, malignancy, fracture, trauma, surgery, central line, OCP, immobilized, sepsis, recent travel, CKD, smoking, cirrhosis, obesity)
-- Clinical: *** dyspnea, pleuritic CP, cough, syncope, hemoptysis
-- Exam: *** tachypnea, tachycardia, S4, JVD, Kussmaul (elevated JVP with inspiration), asymmetric edema, pain, warmth, erythema, venous distention, palpable cord, Homans Sign (not sensitive)
-- Data: *** CXR, CTPE, EKG, echo or POCUS, LE dopplers
-- Etiology/DDx: *** anything that causes chest pain or dyspnea; other causes of obstructive shock include tamponade, tension PTX
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u trop, NT-proBNP
-- f/u echo
-- f/u LE dopplers
-- Monitoring: *** continuous telemetry, daily CBC, BMP, coags
-- Oxygen: currently ***; continuous pulse ox for goal >90%; HFNC if needed; avoid PPV
-- AC: *** LMWH if stable and no renal impairment, otherwise heparin bolus/drip; consider thrombolysis if high risk PE; goal to transition to DOAC (i.e apixaban 10mg po BID for 7 days, then 5mg PO BID) once patient stabilized (3 months if provoked, indefinite if unprovoked and low-risk for bleed or a cancer patient)
-- Fluid: consider 500cc bolus if hypotensive, careful not to overload RV if strain
-- Pressor: *** start with levo if needed
PDF coming soon!
Pulmonary emboli most commonly origjnate in the proximal veins in the legs/pelvis. Patients can present in cardiac arrest, or without symptoms depending on the severity. It should be on the differential and considered a "can't miss" in any patient who presents with dyspnea. D-Dimers are sensitive, thus useful for ruling out a PE when used in concert with other clinical findings and lab values. Anticoagulation does not break up the clot, but does prevent further cascading. The body's natural thrombolytic pathways will dissolve the clot over time.
Terminology for risk stratification for PE has changed, but in general, high risk (formerly massive) involves compromising hemodynamics, and the treatment pathway involves more aggressively removing or busting the clot to prevent obstructive shock, hypoxemia, and cardiac arrest.
In patients with massive PE, respect the RV - do not overload the patient with fluids even if they are hypotensive, and avoid intubation if possible since patients will often collapse and code. If patients are crashing, give epinephrine, consider pulmonary vasodilators (either NO or epoprostenol), and get the PERT team involved immediately for consideration of thrombolytics or thrombectomy. Patients with massive PE can be great VA ECMO candidates since they have a largely reversible process as the cause of their deterioration.