Pulmonary embolism resident survival guide: Difference between revisions
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[[Category:Resident survival guide]] | |||
Revision as of 15:35, 13 December 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
Pulmonary embolism (PE) is an acute obstruction of the pulmonary artery or one of its branches by a thrombus, air, tumor, or fat.
Causes
Life Threatening Causes
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Antiphospholipid syndrome
- Antithrombin deficiency
- Factor V Leiden
- Hyperhomocysteinemia
- Long-distance air travel
- Malignancy
- Nephrotic syndrome
- Obesity
- Post surgery
- Pregnancy
- Protein C deficiency
- Protein S deficiency
- Prothrombin mutation
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 | ||||||||||||||||||||||||||||||||||||||||||||||