Mar 30, 2020
Contributor: Dylan Luyten, MD
Educational Pearls:
- After
you diagnose a pulmonary embolism (PE) via CT or VQ scan, we need
to categorize the PE as massive, sub-massive, or just PE to dictate
treatment.
- Massive PE: shock with hypotension due to an
embolism, and the treatment of choice is thrombolysis with IV tPA
with anticoagulation after lysis. Catheter thrombolysis is not used
in the hemodynamically unstable patient but can be done after they
are stable.
- Sub-massive: signs of right heart
strain/failure but hemodynamically stable. This can be EKG changes,
positive biomarkers, or imaging findings. These patients can be
treated with IV heparin as there may benefit from catheter directed
thrombolysis which has been shown to lead to better functional
outcomes.
- Everything else can be stratified to determine
whether inpatient even outpatient treatment is
necessary
-
Pulmonary Embolism Severity Index (PESI) or
Hestia criteria and can help determine if the patient
is better suited for in or outpatient management.
- Non
massive or sub-massive PEs are treated with heparin/Lovenox bridged
to Warfarin, a factor Xa inhibitor (ex. Xarelto), or direct oral
anticoagulants (DOAC).
Editor’s note: intravenous
heparin is preferable to other anticoagulants when considering
interventional radiology as it can be shut off and/or reversed if
necessary prior to procedure
References
1.
Sista, A. et
al. Stratification,
Imaging, and Management of Acute Massive and Submassive Pulmonary
Embolism. 2017
Jul;284(1):5-24
2. Aujesky D, Obrosky DS, Stone
RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ. Derivation and
validation of a prognostic model for pulmonary embolism. Am J
Respir Crit Care Med. 2005 Oct 15;172(8):1041-6
3. Jimenez, D.
et al. Risk stratification of patients with acute
symptomatic pulmonary embolism. Intern Emerg Med. 2016
Feb;11(1):11-8.
Summarized by Jackson Roos,
MS3 | Edited by Erik Verzemnieks, MD