Pulmonary embolism: Difference between revisions
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*'''Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.'''<ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> ''''The mortality benefit may be greatest in patients with right ventricular dysfunction.''' <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref> | *'''Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.'''<ref>Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.</ref><ref>Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7</ref><ref>Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411</ref> ''''The mortality benefit may be greatest in patients with right ventricular dysfunction.''' <ref>Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.</ref> | ||
*'''Bleeding risk is increased with increasing age especially in the group ≥ 65 yo'''<ref>[[Thrombolysis_in_Pulmonary_Embolism_Metanalysis | *'''Bleeding risk is increased with increasing age especially in the group ≥ 65 yo'''<ref>[[Thrombolysis_in_Pulmonary_Embolism_Metanalysis*Outcomes]]</ref> | ||
====Indications==== | ====Indications==== | ||
*Patients with massive PE and acceptable risk of bleeding complications | |||
*Pt w/ submassive PE w/ evidence adverse prognosis + low risk of bleeding complications | |||
**Hemodynamic instability | |||
**Worsening respiratory insufficiency | |||
**Severe Right Ventricular dysfunction | |||
**Major myocardial necrosis | |||
====Thrombolytic Instructions==== | ====Thrombolytic Instructions==== | ||
*Review contraindications | |||
*Discontinue heparin during infusion | |||
*tPA 100mg over 2hr OR 0.6 mg/kg over 2min | |||
*After infusion complete measure PTT | |||
**Once value is <2x upper limit restart anticoagulation | |||
====Absolute contraindications==== | ====Absolute contraindications==== | ||
*Any prior intracranial hemorrhage, | |||
*Known structural intracranial cerebrovascular disease (e.g. AVM) | |||
*Known malignant intracranial neoplasm | |||
*Ischemic stroke within 3mo | |||
*Suspected aortic dissection | |||
*Active bleeding or bleeding diathesis | |||
*Recent surgery encroaching on the spinal canal or brain | |||
*Recent closed-head or facial trauma w/ radiographic evidence of bony fx or brain injury | |||
====Relative contraindications==== | ====Relative contraindications==== | ||
*Age >75 years | |||
*Current use of anticoagulation | |||
*[[PE in Pregnancy]] | |||
*Noncompressible vascular punctures | |||
*Traumatic or prolonged CPR (>10min) | |||
*Recent internal bleeding (within 2 to 4 weeks) | |||
*History of chronic, severe, and poorly controlled hypertension | |||
*Severe uncontrolled HTN on presentation (sys BP >180 or dia BP >110) | |||
*Dementia | |||
*Remote (>3 months) ischemic stroke | |||
*Major surgery within 3 weeks | |||
===[[IVC Filter]]=== | ===[[IVC Filter]]=== | ||
Revision as of 20:49, 3 August 2015
See Pulmonary Embolism in Pregnancy for pregnancy specific information.[1]
Background
Clinical Spectrum of Venous Thromboembolism
Clinical Spectrum of Venous thromboembolism
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[2][3]
Types
Pulmonary Embolism Categorization[4]
Massive: High-risk
Hemodynamically unstable with symptoms of shock
- ACCP 2016 CHEST Guidelines: Sustained hypotension ONLY criteria (systolic BP <90 for at least 15min or requiring inotropic support)
- Previous definitions (e.g. AHA 2011) include cardiac arrest/pulselessness or persistent profound bradycardia (HR <40 with signs of shock)
Submassive: Intermediate-risk
Right ventricular dysfunction (RVD) and/or myocardial necrosis in the absence of persistent hypotension or shock (SBP >90)[5]
- RV dysfunction
- RV dilation or dysfunction on TTE
- "D Sign" on bedside echo (LV takes on a "D" shape due to RV dilation)
- RV dysfunction on CT defined as RV/LV ratio >0.9[6]
- Elevation of BNP (>90)
- ECG findings of right heart strain (see diagnosis below)
- RV dilation or dysfunction on TTE
- Myocardial necrosis: Troponin I >0.4
Non-Massive: Low-risk
No hemodynamic compromise and no RV strain
Sub-Segmental
- Limited to the subsegmental pulmonary arteries
Symptoms
According to the PIOPED II study, these are the most common presenting signs[7]
- Dyspnea at rest or with exertion (73%)
- Pleuritic chest pain (44%)
- Cough (37%)
- Orthopnea (28%)
- Calf or thigh pain and/or swelling (44%)
- Wheezing (21%)
- Hemoptysis (13%)
Signs
- Tachypnea (54%)
- Calf or thigh swelling, erythema, edema, tenderness, palpable cord (47%)
- Tachycardia (24%)
- Rales (18%)
- Decreased breath sounds (17%)
- Accentuated pulmonic component of the second heart sound (15%)
- JVD (14%)
- Fever (3%)
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Diagnosis
Wells Criteria
- Symptoms of DVT - 3pts
- No alternative diagnosis better explains the illness - 3pts
- HR > 100 - 1.5 pts
- Immobilization within prior 4wks - 1.5pts
- Prior history of DVT or PE - 1.5pts
- Active malignancy - 1pt
- Hemoptysis - 1pt
Wells Score
- 0-1 point: Low probability (3.4%)
- 2-6 points: Moderate probability (27.8%)
- 7-12 points: High probability (78.4%)
Workup by Probability
Low Probability
- If low prob and PERC Rule negative, then no workup
- If low prob and PERC Rule positive, then d-dimer
- Age-adjusted D-Dimer in patients <50 yrs old (Age x 10) has increased specificity without changing sensitivity[8][9]
Moderate Probability
- D-dimer
- However, it is unclear whether d-dimer alone is sufficient to rule-out PE[10]
High Probability
- Consider anticoagulation before imaging!
- CTA if GFR >60
- V/Q if GFR <60
Bedside Ultrasound
- Ultrasound can help diagnosis in equivocal cases
- Assess for right ventricular strain (RVS) and McConnell's sign
- RVS is associated with statistically significant worse outcome[11]
Treatment
Supportive care
- Give IVF to increase preload
Anticoagulation
- Indicated for all patients with confirmed PE or high clinical suspicion (don't wait for imaging)
- Treatment options:
- LMWH SC
- 1st line for most hemodynamically stable pts
- contraindicated in renal failure
- Enoxaparin 1 mg/kg SC q12h
- Dalteparin 200 IU/kg SC q24h, max 18,000 IU
- Unfractionated Heparin
- Consider in pts w/:
- Persistent hypotension
- Increased risk of bleeding
- Recent sx/trauma
- Renal failure (GFR <30)
- Morbid obesity or anasarca (poor sc absorption)
- Thrombolysis is being considered
- 80 units/kg bolus; then 18 units/kg/hr
- Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
- Consider in pts w/:
- LMWH SC
Thrombolysis
- Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.[12][13][14] 'The mortality benefit may be greatest in patients with right ventricular dysfunction. [15]
- Bleeding risk is increased with increasing age especially in the group ≥ 65 yo[16]
Indications
- Patients with massive PE and acceptable risk of bleeding complications
- Pt w/ submassive PE w/ evidence adverse prognosis + low risk of bleeding complications
- Hemodynamic instability
- Worsening respiratory insufficiency
- Severe Right Ventricular dysfunction
- Major myocardial necrosis
Thrombolytic Instructions
- Review contraindications
- Discontinue heparin during infusion
- tPA 100mg over 2hr OR 0.6 mg/kg over 2min
- After infusion complete measure PTT
- Once value is <2x upper limit restart anticoagulation
Absolute contraindications
- Any prior intracranial hemorrhage,
- Known structural intracranial cerebrovascular disease (e.g. AVM)
- Known malignant intracranial neoplasm
- Ischemic stroke within 3mo
- Suspected aortic dissection
- Active bleeding or bleeding diathesis
- Recent surgery encroaching on the spinal canal or brain
- Recent closed-head or facial trauma w/ radiographic evidence of bony fx or brain injury
Relative contraindications
- Age >75 years
- Current use of anticoagulation
- PE in Pregnancy
- Noncompressible vascular punctures
- Traumatic or prolonged CPR (>10min)
- Recent internal bleeding (within 2 to 4 weeks)
- History of chronic, severe, and poorly controlled hypertension
- Severe uncontrolled HTN on presentation (sys BP >180 or dia BP >110)
- Dementia
- Remote (>3 months) ischemic stroke
- Major surgery within 3 weeks
IVC Filter
- Indications
- anticoagulation contraindicated in pt with PE
- failure to attain adequate anticoagulation during treatment
See Also
Thrombolytics for pulmonary embolism
- Clinical Page
- Research summary page: EBQ:Thrombolysis in Pulmonary Embolism Metanalysis
Disposition
External Links
- MDCalc - Well's Criteria for Pulmonary Embolism
- MDCalc - PERC Rule for Pulmonary Embolism
- MDCalc - Geneva Score for Pulmonary Embolism
References
- ↑ D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long
- ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
- ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
- ↑ Jaff MR et al. Management of massive and submassive pulmonary embolism, ileofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830. doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21
- ↑ Martin C et al. Systemic thrombolysis for pulmonary embolism: a review. P T. 2016 Dec; 41(12):770-775
- ↑ Becattini C et al. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J. 2011 Jul;32(13):1657-63. doi: 10.1093/eurheartj/ehr108. Epub 2011 Apr 18.
- ↑ Stein PD et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871.
- ↑ Schouten, HJ, et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BJM. 2013; 346:f2492.
- ↑ Adams, D, et al. Clinical utility of an age-adjusted D-dimer in the diagnosis of venous thromboembolism. Ann Emerg Med. 2014; 64:232-234.
- ↑ ACEP Clinical Policy. http://www.acep.org/Content.aspx?id=80787
- ↑ Taylor, RA, et al. Point-of-care focused cardiac ultrasound for prediction of pulmonary embolism adverse outcomes. The Journal of Emergency Medicine. 2013; 45(3):392–399.
- ↑ Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.
- ↑ Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7
- ↑ Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411
- ↑ Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.
- ↑ Thrombolysis_in_Pulmonary_Embolism_Metanalysis*Outcomes