Pulmonary embolism resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby

For pulmonary embolism smart algorithm click here

Causes

Life Threatening Causes

Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.

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