Pulmonary Embolism
Considerations
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Acute life threatening hypoxemia, RV failure, cardiogenic shock, PEA arrest
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Hemodynamic goals:
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Support RV filling/contractility, minimize pulmonary vascular resistance, maintain preload
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High risk of cardiac collapse upon initiation of PPV
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Life saving maneuvers: thrombolysis, thrombectomy, inotropes, pulmonary vasodilators
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Perioperative bridging of anticoagulation, always consider IVC filter
Management
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Admission to monitored setting
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O2 supplementation as required
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Consultation with ICU/respirology
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Start anticoagulation immediately (IV heparin, low molecular weight heparin)
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If anticoagulation contraindicated → consider IVC filter (controversial)
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Hemodynamic instability: similar to treatments of pulmonary hypertension:
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Vasopressors to maintain RV perfusion
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Intravascular fluid therapy as per CVP, PAC, TEE
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Cautious especially with RV dysfunction: only 500-1000 cc at a time
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Inotropes if RV dysfunction: dobutamine, epinephrine
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Inodilators: milrinone
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Pulmonary artery dilators: nitric oxide, epoprostenol (flolan)
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Intubation & ventilation:
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Avoid if possible
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If necessary:
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Very high risk for cardiac collapse
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Ensure pre-induction arterial line/central line if possible
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Have vasopressors in-line
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Titrated induction with avoidance of hypoxemia/hypercarbia (bag mask once not breathing)
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Avoid high intrathoracic pressures, hypercarbia & hypoxemia
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Thrombolytic therapy:
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Indications:
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Shock: sBP <90 or ↓ sBP of 40 from baseline
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Cardiac arrest
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Severe hypoxemia
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RV dysfunction
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Patent foramen ovale
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Dose: tPA 100mg IV over 2 hours
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Embolectomy:
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Catheter embolectomy
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Surgical embolectomy
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ECMO if all else fails