Pulmonary Embolism 

 

 

Considerations 

 

  • Acute life threatening hypoxemia, RV failure, cardiogenic shock, PEA arrest

  • Hemodynamic goals:

    • Support RV filling/contractility, minimize pulmonary vascular resistance, maintain preload

    • High risk of cardiac collapse upon initiation of PPV 

  • Life saving maneuvers: thrombolysis, thrombectomy, inotropes, pulmonary vasodilators

  • Perioperative bridging of anticoagulation, always consider IVC filter

 

 

Management

 

  • Admission to monitored setting 

  • O2 supplementation as required

  • Consultation with ICU/respirology  

  • Start anticoagulation immediately (IV heparin, low molecular weight heparin) 

  • If anticoagulation contraindicated → consider IVC filter (controversial)

  • Hemodynamic instability: similar to treatments of pulmonary hypertension: 

    • Vasopressors to maintain RV perfusion

    • Intravascular fluid therapy as per CVP, PAC, TEE

      • Cautious especially with RV dysfunction: only 500-1000 cc at a time 

    • Inotropes if RV dysfunction: dobutamine, epinephrine 

    • Inodilators: milrinone 

    • Pulmonary artery dilators: nitric oxide, epoprostenol (flolan)

  • Intubation & ventilation:

    • Avoid if possible 

    • If necessary:

      • Very high risk for cardiac collapse 

      • Ensure pre-induction arterial line/central line if possible 

      • Have vasopressors in-line 

      • Titrated induction with avoidance of hypoxemia/hypercarbia (bag mask once not breathing) 

      • Avoid high intrathoracic pressures, hypercarbia & hypoxemia 

  • Thrombolytic therapy: 

    • Indications: 

      • Shock: sBP <90 or ↓ sBP of 40 from baseline 

      • Cardiac arrest 

      • Severe hypoxemia 

      • RV dysfunction 

      • Patent foramen ovale 

    • Dose: tPA 100mg IV over 2 hours 

  • Embolectomy: 

    • Catheter embolectomy 

    • Surgical embolectomy 

  • ECMO if all else fails