Pulmonary Embolism

# *** Risk Pulmonary Embolism

Assessment

• History: PESI score, AC use/adherence, prior VTE, risk factors, bleeding risk
• Clinical/Exam: dyspnea, chest pain, vitals, cardiopulmonary exam, extremities
• Data: CTAP, echo (RV function), LE dopplers, EKG, troponin/NT-proBNP, lactate

Plan

‍Workup

• Labs: Troponin/NT-proBNP, CBC, CMP, coags
• Imaging: echo for RV function; can consider LE dopplers
• Monitoring: continuous telemetry and pulse oxy

Treatment

• Oxygen: goal >92%; HFNC is needed, best to avoid PPV if c/f right heart strain
• Anticoagulation:
  • If unstable or renal insufficiency, start wtith UFH bolus/drip
  • Goal to start DOAC > LMWH once stabilized with plan to treat for 3-6 months if provoked or indefinitely if unprovoked or an irreversible VTE risk factor
  • Apixaban 10mg BID for 7 days followed by 5mg BID
  • Rivaroxaban 15mg BID for 21 days followed by 20mg daily with dinner
• Fluid: can begin with 500cc bolus if e/o hypotension, careful not to overload RV
• Pressor: if needed, often start with norepinephrine
• Advanced Therapies:
  • Intermediate-high: Consider catheter intervention after 24-48h if no improvement
  • High-risk: discuss systemic lysis, catheter interventions, thrombectomy, and VA-ECMO

# *** Risk Pulmonary Embolism

Assessment

PESI score, risk factors, bleeding risk, symptoms, evidence of RV dysfunction, evidence of DVT

Plan

Workup

• Labs:
• Imaging:
• Monitoring:

Treatment

• Oxygen:
• Anticoagulation: UFH, LMWH, DOAC
• Fluid:
• Pressor:
• Advanced Therapies: lytics, CDI, thrombectomy