Here I discuss about the diagnosis and management of Pulmonary embolism in the Emergency Department based on the contemporaneous evidence.

1. Management of
Pulmonary Embolism in
Emergency Department
Dr. A. Barai
MBBS, MRCS Ed, MSc (Critical acre)
Registrar in Emergency Medicine

2. • 26 years old male
• Otherwise fit and healthy
HOPC:
• Collapsed inside the house while standing
• Unresponsive for 5 minutes
• Diaphoretic and tachypnoeic
• Computer engineer by profession
• Has been in front of the computer for 18 hours a day for a
month without any break
Case 1Case 1

3. O/E:
• Pulse 128/min, regular
• BP: 126/72 mmHg
• RR 32/min
• Sats: 90% RA
• ECG: Sinus tachycardia. S1Q3T3 pattern
• ABG: PO2= 56 mmHg
• CXR: Normal
• Doppler USS: DVT in left leg.
• VQ scan: Perfusion defect in right lower lobe.

4. Treatment:
• Unfractionated heparin IV followed by
• Oral Warfarin

6. Introduction
• Pulmonary embolism (PE) is a medical emergency
where pulmonary artery or its branches are blocked
with embolic substances most commonly blood clots
• Most cases are not life threatening.
• Incidence: 600,000/year in USA
• Mortality rate: 50,000 to 200,000/yr in US

7. Types of PE
• Massive PE: Acute PE with obstructive shock or SBP
<90 mmHg for > 15 minutes or shock
• Sub-massive PE: Acute PE without systemic
hypotension (SBP ≥90 mm Hg) but with either RV
dysfunction or myocardial necrosis
• Non-massive or low risk PE: None of the above
severe features.
Jaff MR, et al. (2011)

8. Diagnosis
• Risk stratification
• Clinical examination
• Bed side tests
• Laboratory tests
• Imaging techniques

9. Risk factors
• Alteration of blood flow:
– Prolonged immobilisation,
– Obesity,
– Pregnancy,
– Cancer
• Factors in blood vessel wall:
– Surgery,
– Catheterisation.
– Trauma
• Hypercoagulable states:
– Estrogen containing OCP,
– Genetic thrombophilia (Factor V Leiden deficiency, Protein C and
Protein S deficiency, antithrombin III deficiency etc.),
– Acquired thrombophilia (antiphospholipid syndrome, nephrotic
syndrome, paroxysmal nocturnal hemoglobinuria)

10. Risk stratification
• PERC Rule
• Wells score for PE
• Modified Geneva score for PE

11. PERC

12. PERC
Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic testing in
emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;2:1247–55.

13. Wells score for PE

14. Investigations
• Bed side tests: ECG, ABG
• Blood tests: D-dimer, FBC, Troponin, UEC
• Imaging techniques: Ultrasound/ Doppler scan,
Chest xray, CTPA, V/Q scan, Echocardiogram

15. ABG findings in PE
• pH= ↑
• PaO2= ↓
• PaCO2= ↓
• HCO3= Normal
• Aa gradient= Large
Aa gradient= PAO2- PaO2

16. Chest xray
• Mostly normal findings
• Done to exclude other pathology
• Plural effusion
• Specific signs:
- Hampton’s hump
- Westermark sign

17. Hampton’s hump

18. Westermark sign

19. ECG findings in PE
• Normal sinus rhythm
• Sinus tachycardia
• Tall peaked T waves in V1- V4
• S1Q3T3 pattern: Not specific. Can be seen in any Cor
pulmonale syndrome
• RBBB

20. S1Q3T3 pattern ECG

21. D-dimer in PE
• D-dimer is a type of Fibrin degradation product
• Can be raised due to a number of reasons
• Negative D-dimer rules out PE/DVT in 98% cases
• False positive D-dimer: infection, pregnancy, renal
failure, post-operative

22. Echocardiogram in PE

23. Doppler USS

24. CTPA
Indications:
- Suspected PE
Contra-indications:
- Renal failure
- Pregnancy
- Allergy to radio-contrast
Procedure:
- Radioactive iodine administered IV
- CT scan performed

28. Ventilation-perfusion scan
Indications:
- Renal failure
- Pregnancy
Procedure:
- Ventilation scan with Xenon inhalation
- Perfusion scan with Tc99m labelled radioactive dye
infusion
- Scan V/Q
- Result: unmatched V/Q

33. Pitfalls of CTPA
• Average radiation exposure is 12.4-31.8 mSV.
• This was estimated to increase the risk of breast cancer by
1.004 to 1.042 and lung cancer from 1.005 to 1.076.
• The excess risk of cancer for individuals over 55 would be less
than 1%;
• In a young 20-year-old woman this would be estimated to
increase the relative lifetime risk of breast or lung cancer by
1.7 to 5.5%.
(Hurwitz et al. 2007)

35. Treatment options
• Symptomatic treatment:
– ABCD approach
– Oxygen
– Analgesia
• Anticoagulation:
– IV Heparin
– S/C LMWH eg Enoxaparine, Dalteparine
– Oral Warfarin
• IVC filter: If there is contra-indications for anti-coagulation
• Thrombolysis: tPA eg Alteplase, Tenectaplase
• Surgical procedures: Pulmonary embolectomy

36. Treatment options
• Massive PE: Thrombolysis/embolectomy
• Sub-massive PE: Strongly consider
thrombolysis/embolectomy but need to
balance risk of bleeding
• Non-massive PE: Anticoagulation

38. Thrombolysis
• Indications:
– Massive PE
– Sub-massive PE where risk of bleeding low
• Contraindications:
– Bleeding, recent stroke, HI, current GI bleeding,
bleeding PUD, surgery within 7 day, prolonged
CPR
• Drugs:
– Alteplase 100mg IV: 15mg IV stat followed by
85mg over 2 hours
– Followed by Heparin infusion

39. Anticoagulation
• IV Heparin:
– 80 units/kg bolus followed by
– 18 units/kg infusion
• Monitor APTT 60-90 sec
• Side effects:
– HITS (Heparin induced thrombocytopenia
syndrome): paradoxical hypercoagulable state
leads to clots
– Bleeding

40. Dilemma

41. • Thrombolysis in normotensive patients with acute PE was
associated with increased mortality (Riera-Mestre, A.et al.
2012).
• European Society of Cardiology (ESC) guidelines suggest
assessing for RV dysfunction (using echocardiography, CT or
B-type natriuretic peptide) or ischaemia (troponin) to aid risk
stratification.(Torbicki A, 2008).
• Use of tenecteplase in submassive PE (PEITHO) observed
rates of major bleeding of 6.3% and Intracranial haemorrhage
of 2%.
Dilemma1:Dilemma1: Submassive PE

42. • Major bleeding occurred in >50% of patients receiving
thrombolysis within 1 week of surgery and in 20% of patients
thrombolysed 1–2 weeks postoperatively. (Condliffe, R. et al.
2014).
• Thrmbolysis is a relative contraindication in these patient
groups. (American College of Chest Physicians Guidelines)
Dilemma2:Dilemma2: Recent surgery

43. • Thrombolytic agents for PE should be administered
peripherally.
• Alteplase: 10mg IV bolus followed by 90mg over 1-2
hours.
• Alternative drugs: tenecteplase, streptokinase,
urokinase
• If already on LMWH: Start IV Heparin 18 hours after
last dose of LMWH
Dilemma3Dilemma3::Patient on LMWH

44. • Echocardiogram to confirm right heart strain
• Thrombolysis: Alteplase 50mg IV bolus
(Kadner et al. 2008)
• Emergency pulmonary embolectomy
• If cause of arrest unclear: No thrombolysis
Dilemma4:Dilemma4: Arrest or periarrest

45. • If a patient with acute PE fails to respond to initial
anticoagulation, with worsening cardiovascular
instability and/or respiratory failure, then
thrombolysis should be considered.
• In the MAPPET-3 study of submassive PE, delayed
thrombolysis was performed in 23% of patients
treated initially with heparin, with no difference in
mortality compared with patients receiving up-front
thrombolysis.
(Konstantinides et al 2002)
Dilemma5:Dilemma5: Recent PE failed Rx

47. Anticoagulation
Low molecular weight Heparin (LMWH)
Enoxaprin (Clexane): S/C
- 1.5mg/kg/24 hours Or 1mg/kg/12 hours
- 1 mg/kg/24 hours in renal impairment
Duration: 6 to 9 months
Side effect: Low HITS

48. Anticoagulation
• Vitamin K antagonist
• Warfarin:
– 5mg PO initial dose
– Check regular INR 2-3
• Side effects:
– Bleeding
– Unusual bruises
– Headache

49. IVC filter
Indications:
- DVT with massive pulmonary embolus
- Recurrent PE not treatable with anticoagulation
- Absolute contra-indications for anti-coagulation
- Trauma patients

51. PE in Pregnancy
• All three components of Virchow’s triad are affected during
pregnancy
• D-dimer has high negative predictive value. False positive
result is common
• V/Q scan is preferred technique
• CTPA can be done if VQ is inconclusive
• Preferred treatment option: LMWH
• Warfarin is contraindicated

52. Prevention of PE
• Control of obesity
• Stop smoking
• Stockings
• Heparin: 5000 units/day IV
• Enoxaprin: 40 mg/day S/C

53. And finally…
PE is often over-diagnosed;
PE is often under-diagnosed;
Both conditions result in increased cost, morbidity,
mortality and medico-legal issues.

55. References
• Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010 Jul 15;363(3):266-74.
doi: 10.1056/NEJMra0907731. Epub 2010 Jun 30
• Bourjeily G, Paidas M, Khalil H, et al. Pulmonary embolism in pregnancy.
Lancet. 2010;375:500-512
• Hofman, M. S.; Beauregard, J. -M.; Barber, T. W. et al.(2011). 68Ga PET/CT Ventilation-
Perfusion Imaging for Pulmonary Embolism: A Pilot Study with Comparison to Conventional
Scintigraphy. Journal of Nuclear Medicine 52 (10): 1513–1519.
• Jaff MR, et al. Management of massive and submassive pulmonary embolism, iliofemoral
deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific
statement from the American Heart Association. Circulation. 2011 Apr 26;123(16):1788-830.
doi: 10.1161/CIR.0b013e318214914f. Epub 2011 Mar 21. Erratum in: Circulation. 2012 Mar
20;125(11):e495. Circulation. 2012 Aug 14;126(7):e104.
• Mattu, A. PE in pregnancy: A complicated diagnosis. Medscape. August 9, 2010 (Online) URL:
http://www.medscape.com/viewarticle/726318
• Pulmonary embolism. Life in the fast lane. (Online).
http://lifeinthefastlane.com/education/ccc/pulmonary-embolism/

56. • Kline JA, Mitchell AM, Kabrhel C, et al. Clinical criteria to prevent unnecessary diagnostic
testing in emergency department patients with suspected pulmonary embolism. J Thromb
Haemost 2004;2:1247–55.
• Riera-Mestre A, Jimenez D, Muriel A, et al. Thrombolytic therapy and outcome of patients
with an acute symptomatic pulmonary embolism. J Thromb Haemost 2012;10:751–9.
• Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of
acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute
Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276–
315.
• Condliffe R, Elliot CA, Hughes RJ, et al. Management dilemmas in acute pulmonary embolism.
Thorax 2014;69:174–180.
References

57. • Hurwitz LM, Reiman RE, Yoshizumi TT, et al. Radiation dose from contemporary
cardiothoracic multidetector CT protocols with anthropomorphic female phantom:
implications for cancer induction. Radiology 2007; 245:742-750.
• Kadner A, Schmidli J, Schonhoff F, et al. Excellent outcome after surgical treatment of
massive pulmonary embolism in critically ill patients. J Thorac Cardiovasc Surg 2008;136:448–
51.
• Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin
alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143–50.
References

58. Thank you!