II. Indications

III. Precautions: Subsegmental Pulmonary Embolism Controversy

  1. CT Chest has false positives and false negatives
    1. False Positive Rate: 26% read initially as positive, were later over-read as negative
      1. Hutchinson (2015) AJR Am J Roentgenol 205(2): 271-7 +PMID:26204274 [PubMed]
    2. False Negative Rate: 11% read initially as subsegmental, were later over-read as segmental
      1. Pena (2012) J Thromb Haemost 10:496-8 +PMID:22212300 [PubMed]
  2. Subsegmental Pulmonary Embolism treatment has mixed results on outcomes
    1. Some studies have shown worse outcomes with subsegmental Pulmonary Embolism treatment
      1. Carrier (2010) J Thromb Haemost 8(8): 1716-22 +PMID:20546118 [PubMed]
    2. Other studies have shown subsegmental PE to have as significant outcomes as segmental PE
      1. den Exeter (2013) Blood 122(7):1144-9 +PMID:23736701 [PubMed]
    3. Despite minor nature of subsegmental PE, recurrent Pulmonary Embolism may occur without Anticoagulation
      1. Kligerman (2014) AJR Am J Roentgenol 202(1): 65-73 +PMID:24370130 [PubMed]

IV. Grading: Severity

  1. High Risk Pulmonary Embolism (Massive Pumonary Embolism)
    1. Pulmonary Embolism and
    2. Systolic Blood Pressure <90 mmHg or >40 mmHg BP drop from baseline for at least 15 minutes
  2. Intermediate Risk Pulmonary Embolism (Submassive Pulmonary Embolism)
    1. Pulmonary Embolism and
    2. Right ventricular dysfunction (RV Strain)
      1. Serum Troponin elevation or
      2. ntBNP >900 pg/ml or (BNP >90 pg/ml) or
      3. Echocardiogram with right ventricular dilation or hypokinesis
  3. Low Risk Pulmonary Embolism
    1. Pulmonary Embolism and
    2. Normal right ventricular function and
    3. Hemodynamically stable

V. Management: Disposition

  1. Inpatient Anticoagulation until therapeutic and stable
    1. Inpatient management is default approach unless outpatient management criteria met
  2. Outpatient Anticoagulation management consideration (Exercise caution)
    1. Precautions
      1. Inpatient management is required for certain conditions
        1. Active cancer
        2. Pregnancy
        3. Pulmonary Embolism occurred while on therapeutic doses of Anticoagulation
      2. Oupatient management should only be considered if consistent with local expert opinion
        1. Must be supported by local protocols
      3. Requires patient Informed Consent
        1. Risk of major bleeding
        2. Risk of death up to 2% (if cancer patients excluded)
    2. Criteria for outpatient management (all criteria should be met)
      1. Patient must be able to comply with outpatient Anticoagulation
      2. Pulmonary Embolism Severity Index (PESI) Score <66 (Class 1)
        1. As of 2015, PESI <86 (low risk) may be reasonable for discharge
      3. Hestia Criteria negative
        1. See Hestia Criteria
      4. Reassuring appearance with normal Vital Signs
        1. Hemodynamically stable and normotensive
        2. No Hypoxia (Oxygen Saturation >90%)
        3. No intervention needed (e.g. no thrmobolysis or embolectomy)
      5. Troponin normal
      6. No signs of right ventricular strain
      7. No contraindicating conditions (cancer, pregnancy)
      8. No Anticoagulation increased risks
        1. Recent significant bleeding, active bleeding or high risk of bleeding
        2. Severe liver disease
        3. Severe renal disease (Creatinine Clearance <30 ml/min)
        4. Platelet Count >70k
        5. History of Heparin Induced Thrombocytopenia
      9. No intractable pain
        1. Expected need for IV Analgesics >24 hours (e.g. required at least 2 IV doses in ED)
    3. References
      1. Aujesky (2011) Lancet (2011) 378(9785): 41-8 [PubMed]
      2. Otero (2010) Thromb Res 126(1):e1-5 [PubMed]
      3. Vinson (2012) Ann Emerg Med 60(5): 651-62 [PubMed]
      4. Kearon (2016) Chest 149(2): 315-52 [PubMed]
      5. Zondag (2011) J Thromb Haemost 9(8): 1500-7 +PMID:21645235 [PubMed]

VI. Management: Anticoagulation

  1. See Anticoagulation in Thromboembolism
  2. Consider Heparin prior to imaging in high likelihood Pulmonary Embolism
    1. Reasonable in high risk cases
    2. Lack of study data to support as standard of care
    3. Risk of adverse outcome (i.e. bleeding complications)

VII. Management: General Approach

  1. Consider Thrombophilia work-up
    1. See Thrombophilia
    2. Reserve blood for tests prior to Anticoagulation
    3. Consider underlying malignancy in unprovoked PE
  2. Supplemental Oxygen
  3. Bed rest is not necessary
    1. Does not prevent new or fatal PE of bleeding
    2. Trujillo-Santos (2005) 127:1631-6 [PubMed]

VIII. Management: Pregnancy

  1. See Pulmonary Embolism in Pregnancy
  2. Anticoagulation
    1. Low Molecular Weight Heparin
    2. Contraindicated agents: Warfarin, Factor Xa Inhibitor (e.g. Rivoroxaban)
  3. IVC Filter
    1. Indicated for Pulmonary Embolism within 4 weeks of estimated delivery date
  4. Thrombolysis is absolutely contraindicated (EXCEPT in life threatening, massive PE)
    1. Risk of major bleeding 2.6%
    2. Consider in life-threatening massive Pulmonary Embolism if not near term
    3. Gartman (2013) Obstet Med 6:105-11 [PubMed]

IX. Management: Massive Pumonary Embolism (Severe cardiovascular compromise)

  1. See Pulmonary Embolism Evaluation with Echocardiogram
  2. Indications (see grading above)
    1. Massive Pumonary Embolism
    2. Intermediate Risk Pulmonary Embolism (Submassive Pulmonary Embolism)
      1. Controversial for Thrombolytic use (evaluate on a case by case basis)
      2. Evidence as of 2017 does not support Thrombolytic use for submassive PE
      3. See Thrombolysis in Massive Pulmonary Embolism
        1. Reviews benefits and risks of Thrombolysis in Intermediate Risk PE
  3. Intervention options (includes Anticoagulation as above)
    1. Thrombolytic Therapy
      1. Confirm no Thrombolytic Contraindications
      2. See Thrombolysis in Massive Pulmonary Embolism
    2. Surgical embolectomy
      1. Lower mortality and complications than Thrombolysis
      2. Gulba (1994) Lancet 343:576-7 [PubMed]
    3. Intervention Radiology, catheter directed Thrombolysis
      1. Variable evidence and some studies have shown benefit while others have not
      2. Piazza (2015) JACC Cardiovasc Interv 8(10): 1382-92 +PMID: 26315743 [PubMed]
  4. References
    1. Jaff (2011) Circulation 123: 1788-830 [PubMed]

XI. References

  1. Orman and Mattu in Herbert (2015) EM:Rap 15(12): 8-10
  2. Vibhakar (2015) Crit Dec Emerg Med 29(9): 2-8
  3. Wilbur (2012) Am Fam Physician 86(10):913-9 [PubMed]

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