Pulmonary embolism resident survival guide: Difference between revisions
Jump to navigation
Jump to search
Rim Halaby (talk | contribs) No edit summary |
Rim Halaby (talk | contribs) |
||
| Line 40: | Line 40: | ||
=== Step 2: Use A Risk-Stratified Approach to Treat the Patient with Pulmonary Embolism === | === Step 2: Use A Risk-Stratified Approach to Treat the Patient with Pulmonary Embolism === | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01=Confirmed PE}} | {{familytree | | | | | | | | | A01 | | | | | |A01='''Confirmed [[PE]]'''}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B01 | | | | | |B01=Assess Clinical<br>Stability}} | {{familytree | | | | | | | | | B01 | | | | | |B01='''Assess Clinical'''<br>'''Stability'''}} | ||
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }} | {{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }} | ||
{{familytree | | C01 | | | | | | | | | | | |C02|C01=Unstable|C02=Stable}} | {{familytree | | C01 | | | | | | | | | | | |C02|C01=Unstable|C02=Stable}} | ||
{{familytree | | |!| | | | | | | | | | | | | |!| }} | {{familytree | | |!| | | | | | | | | | | | | |!| }} | ||
{{familytree | | D01 | | | | | | | | | | | |D02|D01=Blood | {{familytree | | D01 | | | | | | | | | | | |D02|D01=[[Blood pressure]] ≦ 90mm <br> Drop in [[BP]] ≧ 40mm for > 15 min|D02='''Assess [[RV]] function''' <br> '''Biomarkers of injury'''}} | ||
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}} | {{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}} | ||
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Thrombolysis<br>Catheter embolectomy<br>Surgery|E02=No Dysfunction<br>No | {{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=[[Thrombolysis]]<br>[[Catheter embolectomy]]<br>[[Surgery]]|E02=No Dysfunction<br> + <br>No injury |E03=Dysfunction<br> + <br>No injury|E04=Dysfunction<br> + <br> Injury}} | ||
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | }} | {{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | }} | ||
{{familytree | | | | | | | | | | | | F01 | | F02 | | | F03 |F01= | {{familytree | | | | | | | | | | | | F01 | | F02 | | | F03 |F01=[[Anticoagulation]]<br>Early discharge|F02=[[Anticoagulation]]<br>Ward admission|F03=[[Thrombolytics]]<br> [[ICU]] admission}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 13:59, 4 August 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby
For pulmonary embolism smart algorithm click here
Definition
Causes
Life Threatening Causes
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Common Causes
Management
Step 1: Establish The Diagnosis Of Pulmonary Embolism
In hospitals that have experience in performing and interpreting CT pulmonary angiography, the following flowchart approach can be adopted.
| Determine chances of PE | |||||||||||||||||||||||||||||||||
| Low chance | High chance | ||||||||||||||||||||||||||||||||
| D-dimer | |||||||||||||||||||||||||||||||||
| <500 ng/ml | >500 ng/ml | CT Pulmonary angiography | |||||||||||||||||||||||||||||||
| PE excluded | Negative | Positive | |||||||||||||||||||||||||||||||
| PE excluded | PE confirmed | ||||||||||||||||||||||||||||||||
Note: If there is a high clinical suspicion of pulmonary embolism, then anticoagulation can begin with a parenteral agent such as unfractionated heparin during the process of performing the diagnostic studies.
Step 2: Use A Risk-Stratified Approach to Treat the Patient with Pulmonary Embolism
| Confirmed PE | |||||||||||||||||||||||||||||||||||||||||||||||
| Assess Clinical Stability | |||||||||||||||||||||||||||||||||||||||||||||||
| Unstable | Stable | ||||||||||||||||||||||||||||||||||||||||||||||
| Blood pressure ≦ 90mm Drop in BP ≧ 40mm for > 15 min | Assess RV function Biomarkers of injury | ||||||||||||||||||||||||||||||||||||||||||||||
| Thrombolysis Catheter embolectomy Surgery | No Dysfunction + No injury | Dysfunction + No injury | Dysfunction + Injury | ||||||||||||||||||||||||||||||||||||||||||||
| Anticoagulation Early discharge | Anticoagulation Ward admission | Thrombolytics ICU admission | |||||||||||||||||||||||||||||||||||||||||||||
Step 3: Assess Treatment Response and Need for Device Based Therapy
| Acute PE confirmed | |||||||||||||||||||||||||||||||||||||||||||||||
| Anticoagulation contraindicated ? | |||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||
| IVC filter | Risk Stratification | ||||||||||||||||||||||||||||||||||||||||||||||
| Low-risk PE | Submassive PE | Massive PE | |||||||||||||||||||||||||||||||||||||||||||||
| Anticoagulation | Anticoagulation | ||||||||||||||||||||||||||||||||||||||||||||||
| Assess clinically for evidence of increased severity | |||||||||||||||||||||||||||||||||||||||||||||||
| Evidence of Shock (SBP <90 mmHg) or respiratory failure | Is Thrombolytic Contraindicated? | ||||||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||
| Surgical emblectomy or catheter based interventions | Hold Anticoagulation, Give Thrombolytics then resume Anticoagulations | ||||||||||||||||||||||||||||||||||||||||||||||
| Patient shows clinical improvement | |||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||
| Surgical emblectomy or catheter based interventions | Continue anticoagulation | ||||||||||||||||||||||||||||||||||||||||||||||