Emergency Medicine - VTE

1. Massive PE –
Thrombolysis
- Grand
Round
08/10/21
MISBAH MOHAMMAD
ADULT & PAEDIATRIC
EM CONSULTANT

2. Objectives
- Case scenarios x 4
- Massive PE with hemodynamic instability
- Role of PoCUS
- Thrombolysis
- ESC Guidance
- Decision making process

3. Case scenario 1
- Emergency buzzer pulled in ED Resus
- Patient attended by cardiac arrest team including EM Consultant, ITU SpR &
Cardio SpR
- 50y F morbidly obese pt with *TLoC & fall from stairs due to TLoC - ?Trauma
- Desaturation on air with SpO2 80% on high flow Oxygen prior to CA
- Bedside Echo confirmed RV strain
*Prandoni et al, PE in Syncope Italian Trial. N Engl J Med 2016; 375:1524-1531

4. Case scenario 1 cont
- Multi-disciplinary decision making
- Mental model sharing
- Pros & cons – anticipation & planning for complication
- Thrombolysed – IV Alteplase 50 mg stat as per trust guidance
- Pt woken up

5. Case scenario 2*
- 35y F with Covid+ & Asthma
- Desatting on air & high flow Oxygen – SpO2 50% on NRB – Cyanotic
- RSI – SpO2 plummeted 40s – 20s – 10s – DOPE
- Cardiac arrest in ED
- PoCUS s/o RV strain – thrombolysed
- Outcome unfavorable
*AIUM Covid-19 PoCUS update Sep 2020

6. Case scenario 3
41 yrs old lady with suspected PE
Hemodynamically stable
Desaturating on high flow oxygen
Bedside Echo
Thrombolysis done after Cardiac Arrest
CTPA confirmed PE

7. Case scenario 4
- 94y elderly female
- Desatting on high flow Oxygen
- Bedside Echo confirmed massive PE f/b CTPA
- Hemodynamically unstable in ED Resus
- Shared decision making with patient
- Agreed for anticoagulation & DNACPR - not for thrombolytics

8. Pathology
Key factors contributing
to haemodynamic
collapse and death in
acute pulmonary
embolism

9. Haemodynamic instability - acute high-risk
PE

10. POCUS
Bedside Echo
– signs of RV Strain

11. Classification of PE severity & risk of early (in-
hospital or 30 day) death

12. Decision
algorithm
Suspected PE with
hemodynamic
instability

13. Decsion
algorithm
cont.
Patient with
Acute PE

14. Thrombolysis regimen
· Contrast allergy
Imaging should be completed within 1 hour
If this is not possible, give Clexane 1.5 mg / kg sc while awaiting scan
xaparin)
rtension
orrhage
nths
tis
e dose
e dose
y if already
opidogrel
Is scan positive?
Admit
Refer Medics bleep 001
Commence
Clexane 1.5 mg/kg sc od
unless contraindicated
No
Yes
Suitable for ambulatory care?
Exclusions: 1100 - 1900 only
· Abnormal vital signs eg GCS < 15, P > 110, sBP < 100,
RR > 30, Sats < 95%, Temp < 36o
C
· Age > 65
· History of cancer, cardiorespiratory co-morbidities or mental
health problems
· Active bleeding or coagulopathy
· Inadequate social circumstances
Ambulatory Care
1100 - 1900
Discuss with Ambulatory
Dr bleep xxx
Med reg 001?
Yes No
Massive
PE
Tests for confirmed PE
FBC, Ca, LFT, CXR,
urinalysis
Thrombolysis
Indications:
Senior clinical decision
Consider discussion with
Interventional Radiologist, via xxxx
Suspected or confirmed massive PE
with:
· Cardiac arrest / peri-arrest
Alteplase 50 mg iv stat
and
2nd
50 mg iv over 1 hour post ROSC
· Clinical cardiogenic shock
Alteplase 10 mg iv over 1-2 mins
then
Alteplase 90 mg iv over 2 hrs
-Total dose 1.5 mg/kg if < 65 kg
· Normotensive but with evidence of
significant right heart strain on
echo or positive troponin
(weaker evidence but may reduce incidence of
pulmonary hypertension)
Alteplase 50 mg over 1 hour
· Give Clexane 1.5 mg/kg sc od post
thrombolysis
In cardiac arrest, consider
continuing CPR for 60 - 90 minutes
after thrombolysis

15. Treatment of RV failure in acute high-risk
PE

16. Decision making
– ‘to/not to’ Thrombolyse
- Multi-disciplinary based
- Shared decision making
- Evidence & guidance based
- Individual case based – risk vs benefit
- Time critical

17. Multidisciplinary PE teams (PERT)
- PE rapid response team
- Currently functional in GSTT
- Their own protocol to accept patient for thrombolysis/thrombectomy
consideration
- team of specialists from different disciplines including, for example, cardiology,
pulmonology, haematology, vascular medicine, anaesthesiology/intensive care,
cardiothoracic surgery, and (interventional) radiology

18. Any Question?

19. Summary
- Massive PE with hemodynamic instability – high stake diagnosis
- Team based approach
- Engage team & patient in decision making
- Use of PoCUS
- Early thrombolysis – risk vs benefit

20. THANK YOU
Your feedback is highly appreciated