Basics of PE Management
A 56 y/o male is found in cardiac arrest by his wife. She calls 911. CPR is initiated. Pulseless electrical activity (PEA) is the only rhythm throughout the resuscitation. Finally, ROSC is achieved and the patient is placed on norepinephrine at 30mcg/min, epinephrine at 30 mcg/min and vasopressin at 0.04 U/min.
POCUS shows a dilated right ventricle and empty left ventricle. CTPA shows large pulmonary embolism (PE). 50 mg tenecteplase (TNK) is given over 1-2 hours and the pressors are down titrated. Unfortunately, the patient had a poor neurologic outcome and the family withdrew care.
Take Away #1: Risk Stratify Patients with Possible PE
Geneva (Geneva is best for less experienced trainees because it is not predicated on gestalt)
Take Away #2 Stratify the Type of PE
Massive = PE with Hemodynamic instability
Submassive = No hypotension but signs of right heart strain
Anteriorseptal STE or depression
Anteriolateral T-wave inversion
Massive - give thrombolytics (50mg TNK over 1-2 hours or as an IV push if cardiac arrest.
Submassive - Understand this is a spectrum. Use shared decision making. If on the more severe end of the spectrum, then consider 1/2 dose TPA (50 mg TNK).
Low risk PE - Anticoagulation. Remember, concomitant use of anticoagulation increases bleeding risk!
Take Away #3 Optimize Your Resuscitation
Minimize hypoxia and hypercarbia as these worsen pulmonary vascular resistance and increase right ventricle afterload
Use vasopressors early
Consider Nitric Oxide
½ dose TNK (50 mg) has been shown to have similar mortality outcomes with less incidence of bleeding
Consider ½ dose TNK for submassive
Matthew McClure, DO is a current third year resident at Stony Brook Emergency Medicine.
PEAPET (50mg TNK in cardiac arrest) - https://www.ncbi.nlm.nih.gov/pubmed/27422214/
Wang et al (1/2 vs full dose TPA) - https://www.ncbi.nlm.nih.gov/pubmed/19741062/
PEITHO (Largest RCT, Heparin + TNK vs. Placebo + Heparin) - https://www.ncbi.nlm.nih.gov/pubmed/24716681/
PEITHO long term follow up - https://www.ncbi.nlm.nih.gov/pubmed/28335835/
MOPPET trial (1/2 dose TPA) - https://www.ncbi.nlm.nih.gov/pubmed/23102885/
Full dose vs ½ dose TPA ** If you want to nerd out on “why TNK vs TPA” - https://www.ncbi.nlm.nih.gov/pubmed/24412030/
Edited by Bassam Zahid, MD