Emergency management of Pulmonary Embolisms.pptx

7/27/2019 Emergency management of Pulmonary Embolisms.pptx

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Emergency management of

Pulmonary Embolisms



What is a Pulmonary Embolism?

Goldhaber SZ (2005). "Pulmonary thromboembolism". In Kasper DL, Braunwald E, Fauci AS, et al.. Harrison's Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1561 –65

Blockage of the main artery of the lung or one of

its branches by a substance that has travelledfrom elsewhere in the body through the

bloodstream.



Risk Factors

Goldhaber SZ (2005). "Pulmonary thromboembolism". In Kasper DL, Braunwald E, Fauci AS, et al.. Harrison'sPrinciples of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1561 –65

Recent surgery, especially abdominal/pelvic or hip/knee replacement

Thrombophilia

Leg fracture Prolonged bed rest

Malignancy

Pregnancy/postpartum;pill/HRT



Approach to treatment:

Guidelines on the diagnosis and management of acute pulmonary embolism- European HeartJournal, Volume 29- Issue 18.

Assessment of Severity:

-Low-risk PE is diagnosed when all checked rightventricular dysfunction and myocardial injury markers are

found negative.

-Intermediate-risk PE is diagnosed if at least one RVDor one myocardial injury marker is positive.

-High-risk PE is diagnosed in the presence of shock or persistent arterial hypotension (defined as a systolic blood

pressure <90 mmHg or a pressure drop of ≥40 mmHg for

>15 min if not caused by new-onset arrhythmia,

hypovolaemia or sepsis)





RESUSCITATION:- Respiratory Support: Supplemental oxygen

should be administered if hypoxemia exists.Severe hypoxemia or respiratory failure should

prompt consideration of intubation andmechanical ventilation.

- Haemodynamic support: patients presenting

with acute PE and hypotension. Intravenous fluidadministration is first-line therapy. Administrationof 500 mL of dextran significantly increased thecardiac index from a mean of 1.6 to 2.0 L/min/m2.




Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein

Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension- American Heart Association2011.

Which anticoagulant should be administered?

How much and for how long?

Should thrombolytic therapy be administered?

Should an inferior vena caval filter be placed?

Is embolectomy indicated?



Anticoagulation:

Guidelines on the diagnosis and management of acute pulmonary embolism- European Heart Journal,Volume 29- Issue 18.

Rapid anticoagulation can only be achieved with

parenteral anticoagulants, such as intravenousunfractionated heparin, subcutaneous low-molecular-

weight heparin (LMWH) or subcutaneous

fondaparinux.

Treatment with parenteral anticoagulants is usuallyfollowed by the administration of oral vitamin K

antagonist.

Anticoagulation with unfractionated heparin, LMWH or

fondaparinux should be continued for at least 5 daysand stopped when the international normalized ratio

(INR) lies between 2.0 and 3.0 for at least 2

consecutive days. If warfarin is used, a starting dose of

5 or 7.5 mg is preferred over higher doses.



Anticoagulation:

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein

Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension- American Heart

Association 2011.

Warfarin should be continued for a minimum of 3months after stopping heparin.

Thrombolysis for a high risk PE is 50mg bolus of alteplase.



anticoagulation:

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and

Chronic Thromboembolic Pulmonary Hypertension- American Heart Association 2011.

Therapeutic anticoagulation with subcutaneous LMWH,

intravenous or subcutaneous UFH with monitoring,

unmonitored weight-based subcutaneous UFH, or

subcutaneous fondaparinux should be given to patientswith objectively confirmed PE and no contraindications

to anticoagulation.

Therapeutic anticoagulation during the diagnostic

workup should be given to patients with intermediate

or high clinical probability of PE and no



Thrombolytic Therapy:


First-line treatment in patients with high-risk PE

presenting with cardiogenic shock and/or persistentarterial hypotension.

Intermediate-risk PE- after thorough consideration of

conditions increasing the risk of bleeding. Not usedroutinely.

Thrombolytic therapy should be not used in patients

with low-risk PE.



Thrombolytic Therapy:

Guidelines on the diagnosis and management of acute pulmonary embolism- European Heart Journal,

Volume 29- Issue 18.

Streptokinase-250 000 IU as a loading dose over 30 min,

followed by 100 000 IU/h over 12 –24 h

-Accelerated regimen: 1.5 million IU over 2 h

Urokinase

-4400 IU/kg as a loading dose over 10 min,followed by 4400 IU/kg/h over 12 –24 h

Accelerated regimen: 3 million IU over 2 h

Recombinant tissue Plasminogen Activator

-100 mg over 2 h or 0.6 mg/kg over 15 min(maximum dose 50 mg)



Embolectomy

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and

Chronic Thromboembolic Pulmonary Hypertension- American Heart Association 2011.

Used in:

- High risk PE

- Intermediate risk PE with right ventricular dysfunction

when contraindications exclude thrombolysis.

- Low risk PE to remove a right atrial thrombus or

paradoxical embolus.



Embolectomy

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis,

and Chronic Thromboembolic Pulmonary Hypertension- American Heart Association 2011.

Catheter embolectomy and fragmentation or surgical

embolectomy is reasonable for patients with highriskPE and contraindications to fibrinolysis

High risk PE who remain unstable after receiving

fibrinolysis

Intermediate risk PE judged to have clinical evidence

of adverse prognosis (new hemodynamic instability,

worsening respiratory failure, severe RV dysfunction,or major myocardial necrosis)

low-risk PE or intermediate risk PE with minor RV

dysfunction, minor myocardial necrosis, and no



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Emergency management of Pulmonary Embolisms.pptx

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