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THE MORNING REPORT

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Matthew McClure, DO
Aug 9, 2019

Basics of PE Management


A 56 y/o male is found in cardiac arrest by his wife. She calls 911. CPR is initiated. Pulseless electrical activity (PEA) is the only rhythm throughout the resuscitation. Finally, ROSC is achieved and the patient is placed on norepinephrine at 30mcg/min, epinephrine at 30 mcg/min and vasopressin at 0.04 U/min.

POCUS shows a dilated right ventricle and empty left ventricle. CTPA shows large pulmonary embolism (PE). 50 mg tenecteplase (TNK) is given over 1-2 hours and the pressors are down titrated. Unfortunately, the patient had a poor neurologic outcome and the family withdrew care.

Take Away #1: Risk Stratify Patients with Possible PE

  • PERC

  • WELLS

  • Geneva (Geneva is best for less experienced trainees because it is not predicated on gestalt)

Take Away #2 Stratify the Type of PE

  • Massive = PE with Hemodynamic instability

  • Submassive = No hypotension but signs of right heart strain

  • POCUS findings

  • Elevated BNP

  • Elevated Trop

  • new RBBB

  • Anteriorseptal STE or depression

  • Anteriolateral T-wave inversion

  • Massive - give thrombolytics (50mg TNK over 1-2 hours or as an IV push if cardiac arrest.

  • Submassive - Understand this is a spectrum. Use shared decision making. If on the more severe end of the spectrum, then consider 1/2 dose TPA (50 mg TNK).

  • Low risk PE - Anticoagulation. Remember, concomitant use of anticoagulation increases bleeding risk!

Take Away #3 Optimize Your Resuscitation

  • Minimize hypoxia and hypercarbia as these worsen pulmonary vascular resistance and increase right ventricle afterload

  • Use vasopressors early

  • Consider Nitric Oxide

  • ½ dose TNK (50 mg) has been shown to have similar mortality outcomes with less incidence of bleeding

  • Consider ½ dose TNK for submassive

 

Matthew McClure, DO is a current third year resident at Stony Brook Emergency Medicine.

References


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