1) A study compared the yield of CT pulmonary angiograms (CTPAs) for patients with pulmonary embolism (PE) when clinicians overrode clinical decision support (CDS) guidelines versus adhering to them.
2) The override group had a lower yield of PE detection (4.2% vs 11.2%) and 51.3% lower odds of acute PE compared to the adherent group.
3) Guidelines for PE management include anticoagulation, thrombolysis, catheter-directed thrombolysis, surgical embolectomy, and consideration of inferior vena cava filters depending on the risk level and characteristics of the patient's PE.
Acute pulmonary embolism - risk stratification and managementPrithvi Puwar
what is the guideline recommendation and ideal to be done in management of acute pulmonary embolism. the presentation includes risk stratification, recommendation and approach to investigations (guidelines based) and management options with evidence.
Acute pulmonary embolism - risk stratification and managementPrithvi Puwar
what is the guideline recommendation and ideal to be done in management of acute pulmonary embolism. the presentation includes risk stratification, recommendation and approach to investigations (guidelines based) and management options with evidence.
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.
Updated global adult sepsis guidelines, released in October 2021 by the Surviving Sepsis Campaign (SSC), place an increased emphasis on improving the care of sepsis patients after they are discharged from the intensive care unit (ICU) and represent greater geographic and gender diversity than previous versions.
The new guidelines specifically address the challenges of treating patients experiencing the long-term effects of sepsis. Patients often experience lengthy ICU stays and then face a long, complicated road to recovery. In addition to physical rehabilitation challenges, patients and their families are often uncertain how to coordinate care that promotes recovery and matches their goals of care.
Interstitial Lung Diseases [ILD] Approach to ManagementArun Vasireddy
Diffuse (interstitial) lung disease includes a wide variety of relatively uncommon conditions presenting with characteristic clusters of clinical features and marked by an immune response. There are over 200 specific diffuse lung diseases, many of unknown etiology. The combined incidence is 50 per 100,000, or 1 in 2000 people. Because these conditions cause aberrant lung function, morbidity and mortality due to lung injury and fibrosis are not uncommon. Both environmental and genetic factors are believed to contribute to the development of diffuse lung disease. Antigen processing and presentation are important in the development of the immune response seen in the disease, and it is thought that the likely candidate genes predisposing patients to this category of disease are those of the major histocompatibility complex. Genes that affect the immune, inflammatory, and fibrotic processes may also influence who develops the disease. If we can identify the genes that cause diseases characterized by lung injury and fibrosis, we can eventually develop genetic interventional approaches to treatment.
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.
Updated global adult sepsis guidelines, released in October 2021 by the Surviving Sepsis Campaign (SSC), place an increased emphasis on improving the care of sepsis patients after they are discharged from the intensive care unit (ICU) and represent greater geographic and gender diversity than previous versions.
The new guidelines specifically address the challenges of treating patients experiencing the long-term effects of sepsis. Patients often experience lengthy ICU stays and then face a long, complicated road to recovery. In addition to physical rehabilitation challenges, patients and their families are often uncertain how to coordinate care that promotes recovery and matches their goals of care.
Interstitial Lung Diseases [ILD] Approach to ManagementArun Vasireddy
Diffuse (interstitial) lung disease includes a wide variety of relatively uncommon conditions presenting with characteristic clusters of clinical features and marked by an immune response. There are over 200 specific diffuse lung diseases, many of unknown etiology. The combined incidence is 50 per 100,000, or 1 in 2000 people. Because these conditions cause aberrant lung function, morbidity and mortality due to lung injury and fibrosis are not uncommon. Both environmental and genetic factors are believed to contribute to the development of diffuse lung disease. Antigen processing and presentation are important in the development of the immune response seen in the disease, and it is thought that the likely candidate genes predisposing patients to this category of disease are those of the major histocompatibility complex. Genes that affect the immune, inflammatory, and fibrotic processes may also influence who develops the disease. If we can identify the genes that cause diseases characterized by lung injury and fibrosis, we can eventually develop genetic interventional approaches to treatment.
This was powerpoint was requested by an attending physician to be shared with the Psychiatric providers regarding DVT prophylaxis in patients who may have been on the unit. They include recommendations as outlined by the ACCP 2012 Guidelines for prevention of venous thromboembolism
The use of extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VADs) for both short-term and long-term management of advanced cardiac (and respiratory) failure is increasing. Both thrombotic and haemorrhagic complications are common in patients receiving mechanical support, and such complications are associated with increased morbidity and mortality. Risks of bleeding and of thrombosis vary over time, and according to technical and patient factors. Careful assessment of the risks and benefits of anticoagulation for each patient is therefore a critical component of successful mechanical support.
The approach to anticoagulation for patients receiving VADs varies according to stage of recovery and device. In the immediate post-operative period, bleeding is usually a greater risk than thrombosis and a period free from anticoagulation is usually used. Subsequent initiation of anticoagulation is usually with heparin, with the introduction of warfarin and aspirin over a period of days. Current recommendations include warfarin for all continuous flow devices, usually with the addition of aspirin, and in some cases an additional antiplatelet agent. Target INR and platelet inhibition varies with device, and institution. Testing varies according to device also. Potential pitfalls and problems exist, and these will be highlighted in this session, using a case-based approach.
The management of anticoagulation for patients receiving ECMO varies worldwide, and there are currently limited guidelines. Important factors in decision-making in regards to anticoagulation for ECMO include mode of ECMO, ECMO configuration, ECMO flows, and underlying patient pathology. Strategies for anticoagulation should take each of these factors into consideration. It is also important to recognise that other management techniques to avoid thrombosis are important, such as adequate intracardiac decompression, and promoting cardiac ejection to avoid stasis. Cases will be used to demonstrate important issues and practical management strategies.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
Few data are available with regard to the safety and tolerability of antiplatelet medications in patient with thrombocytopenia
Risk stratification by thrombotic and bleeding risks should be performed.PCI and dengue management should consider the timing of coronary intervention and the severity of the dengue infection.
Management based on expert opinion; this should be determined by the clinician on a case-by-case basis.
Management of Acute Variceal Bleeding based on American Association for The Study of Liver Disease (AASLD) and European Association for The Study of Liver (EASL) guidelines.
Angiotensin neprilysin inhibition in acute decompensated heart failureShadab Ahmad
Sacubitril–valsartan is an angiotensin receptor– neprilysin inhibitor that is indicated for the treatment of patients with symptomatic heart failure with reduced ejection fraction
Similar to Pulmonary embolism management options (20)
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Why follow the guidelines?
• Yield of CT Pulmonary Angiography in the Emergency Department When Providers
Override Evidence-based Clinical Decision Support.
• Compared CTPA yield for PE in clinicians who overrode CDS (Clinical Decision Support)
vs. those adherent to CDS
• Wells Score </= 4 and normal D-dimer or no D-dimer (override group) vs Adherent group
• 2993 CTPAs in 2655 patients.
• 563 had Wells </= 4 and did not undergo D-Dimer testing
• 26 had Wells </= 4 and a normal D-Dimer
• i.e. most overrides due to lack of D-Dimer testing
• Positive for PE 4.2% in override group vs. 11.2%
• After adjustment, the odds of an acute PE finding were 51.3% lower in the override group
3. Definitions
Massive PE
Acute PE with sustained hypotension
(SBP<90mmHg for at least 15 mins or
requiring inotropic support, not due to a
cause other than PE), pulselessness, or
persistent profound bradycardia
(HR<40bpm with signs or symptoms of
shock)
4. Definitions
Submassive PE
Acute PE without systemic hypotension
(SBP >90mmHg) but with either RV
dysfunction or myocardial necrosis
RV Dysfunction:
• RV dysfunction or dilatation on echo
• RV dilatation on CT
• elevated BNP
• ECG changes
Myocardial Necrosis:
• elevated Troponin T
• elevated Troponin I
5. PE Relevance
• It is estimated that there are approximately 17 000 new cases of
venous thromboembolism (VTE) in Australia per year.
Pulmonary embolism (PE) accounts for about 40% of these
events
• 151,923 North-East Metropolitan Perth residents from
01/10/2003 - 31/10/2004
• 87 DVT, 53 PE
• 0.31 per 1000 residents per year
• WHO age-adjusted incidence of 0.21 per 1000
6. PE relevance
• ~20% of all PE are submassive PE
(numbers vary as we get better at
detecting PE)
• a meta-analysis by Cho et al, 2014
found increased short-term mortality
for haemodynamically stable patients
with RV dysfunction (OR 2.29; 13.7%
vs 6.5% without RV dysfunction)
• there may be selection bias, as those
patients that get an echo are more
likely to be sick
• Leads to long term morbidity -
pulmonary hypertension and reduced
functional outcome
8. Anticoagulation
• Parenteral anticoagulants (Heparin/LMWH) overlapping the start of Warfarin Therapy
• RivaroXaban (Factor Xa inhibitor)
• PBS: Initial and continuing treatment of confirmed, acute symptomatic pulmonary embolism
• Rivaroxaban is no worse than enoxaparin plus warfarin for preventing VTE recurrence in initial treatment of
acute DVT or PE
• Contraindicated in severe renal impairment
• Currently no antidote
• Associated with more GI bleeding compared to Warfarin - 3.61/100 patient years vs 2.60, but no significant
difference in Severe or Fatal GI bleeding (ROCKET AF Trial)
• ApiXaban
• Also on the PBS for PE
• Similar in efficacy to Rivaroxaban
• Appears to be associated with a lower bleeding risk - indirect comparisons. More studies required
• DabigaTran - not on PBS for treatment of acute PE. Does have antidote.
9. Thrombolysis
• Pros:
• Less long-term pulmonary hypertension
(MOPETT trial)
• Clots resolve faster
• Patients appear to improve faster clinically
• Decreased death or haemodynamic
instability (PEITHO trial)
• Cons:
• Risk of ICH (2% in >75yo in PEITHO)
• Risk of other haemorrhage (~6% in PEITHO)
• similar improvement at 7 days overall
(~65% reduction in size of total defect
regardless of whether thrombolysed or anti
coagulated)
10. PEITHO Trial (Pulmonary EmbolIsm THrOmbolysis)
• Tenecteplase vs. Placebo for intermediate risk PE
• 1005 patients
• Death or haemodynamic compromise in 2.6% vs 5.6% in
placebo
• Major extra cranial bleeding in 6.3% vs 1.2 % in placebo
• <75yo 4.1% vs 1.5% - not significant
• >75yo 11.1% vs 0.6%
• Intracranial Bleeding in 2% vs 0.2% in placebo
11. MOPETT Trial (Moderate Pulmonary Embolism treated with
Thrombolysis)
• “In patients with submassive PE does low-dose tPA reduce the incidence of
pulmonary hypertension recurrent PE when compared to anticoagulation
alone?”
• 121 patients. single center. unblinded.
• low-dose tPA vs control
• All patients received anticoagulation with LMWH or UFH and warfarin
• Thrombolysis associated with reduction in Pulm. HTN 16% vs 57% in
control - mean follow-up 2.3 years
• No significant difference in rates of recurrent PE
• tPA did not confer a survival benefit
12. Thrombolysis: how to give it
• Tenecteplase - weight-based calculation
• Alteplase
• >65kg given 100mg total
• 10mg bolus, 90mg over next 2 hours
• <65kg adjust total dose not to exceed 1.5mg/kg
• Start heparin infusion
• LMWH efficacy is unknown
13. Thrombolysis: Contraindications
• Absolute contraindications include
• any prior intracranial haemorrhage
• known structural intracranial cerebrovascular disease (eg, arteriovenous malformation)
• known malignant intracranial neoplasm
• ischaemic stroke within 3 months
• suspected aortic dissection
• active bleeding or bleeding diathesis
• recent surgery encroaching on the spinal canal or brain, and
• recent significant closed-head or facial trauma with radiographic evidence of bony fracture or brain injury
• Relative contraindications include
• age >75 years
• current use of anticoagulation
• pregnancy
• non-compressible vascular punctures
• traumatic or prolonged cardiopulmonary resuscitation (>10 minutes)
• recent internal bleeding (within 2 to 4 weeks)
• history of chronic, severe, and poorly controlled hypertension
• severe uncontrolled hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg)
• dementia
• remote (>3 months) ischaemic stroke; and
• major surgery within 3 weeks
14. Intra-Arterial Thrombolysis
• Potential for same benefits as systemic
thrombolysis with lower bleeding risk
• Wire passed through embolus followed by
an infusion catheter with multiple
openings - thrombolytic is then infused to
the clot
• Evidence is lacking - SEATTLE-II trial 2015
15. Endovascular Procedures
• An option when thrombolysis
is contraindicated or the
condition is refractory to
thrombolysis
• Patient preference, institute
and operator preference and
availability
• case-by-case basis
• https://www.youtube.com/
watch?v=cWh1ovlJg24
16. Surgical Embolectomy
• An option when thrombolysis is
contraindicated or the condition is
refractory to thrombolysis
• Pt on CPB
• Usually limited to directly
visualised clot
• Patient preference, institute and
operator preference and availability
• case-by-case basis
• https://www.youtube.com/
watch?v=SzsQWIMYbN8
17. Sir Charles Gairdner Hospital
Pulmonary Embolism Advanced Care Pathway
Non massive &
Low risk submassive PE
• Not clinically compromised
A senior clinician should be involved in the assessment of patients with pulmonary embolism, and discussion between
Emergency medicine, respiratory medicine, cardiothoracic surgery and interventional radiology is encouraged.
These are only guidelines, patients are unique, there is a broad and complex spectrum of presentation, and definitive evidence is limited.
High bleeding
risk
Low bleeding
risk
Accessible PE
(≥ lobar PA involved)
• Surgical
embolectomy
Peripheral PE
• Full dose tPA
Options include:
• Standard anticoagulation
• Catheter directed lysis
• Surgical embolectomy
• ½ dose systemic thrombolysis
Discuss with appropriate specialty:
• Central clot - Respiratory Medicine plus
Cardiothoracic surgery if clinical compromise
• Peripheral clot – Respiratory Medicine
plus Interventional radiology if clinical
compromise
• Plus make ICU aware
•Decision based on:
• Clot burden and location
• High versus low bleeding risk
• Clinical state and comorbidities
• Resource availability
• Patient preference
Accessible PE
(≥ lobar PA involved)
• Surgical
embolectomy
Peripheral PE
• Catheter
directed lysis
Low molecular
weight heparin /
anticoagulation
ICU or HDU / Resp HDUHDU / Resp HDU
Consider discharge if noconcerning features
(see list under high risk submassive PE)
Ensure appropriate follow up – anticoag nurse /
resp / +/- haematology
Otherwise generally admit respiratory medicine
Massive Pulmonary
Embolism
•Ongoing hypotension with significant
clinical compromise
(<90mmHg or > 40 mmHg drop in
systolic BP)
High risk submassive PE
Features from at least 2 of the below categories:
1. Clinical: looks unwell or compromised,
deteriorating, severe hypoxia, syncope hx
2. Imaging: large clot burden, concerning echo
3. Laboratory: Elevated lactate, BNP, troponin
Designed in collaboration and with agreement from Emergency Medicine, Respiratory Medicine, Interventional Radiology and Cardiothoracic Surgery For Review 2017
Reference: Modified from the EMCrit.org website May 2015. http://i2.wp.com/emcrit.org/wp-content/uploads/2014/07/Orens-PE-Algo.jpg James Rippey
18. Sir Charles Gairdner Hospital
Pulmonary Embolism Advanced Care Pathway – additional information
Absolute
• Known allergy / hypersensitivity / adverse reaction to thrombolytics or allergy to
Gentamicin ( a trace residue from the manufacturing process)
• Active or recent internal bleeding within 14 days (excludes menstruation)
• Significant closed head, facial or other severe trauma within past 3 months
• Suspected aortic dissection or pericarditis
• Prior intracranial haemorrhage within past 6 months
• Ischaemic stroke within 3 months or previous haemorrhagic stroke
• Known structural cerebral vascular lesion (AVM or aneurysm)
• Known malignant intracranial or intraspinal neoplasm
• Known severe bleeding disorder
• Recent (within past 2 months) intracranial or intraspinal surgery)
Relative
• Age more than 75 years
• Current anticoagulant use (if on warfarin
only thrombolyse if INR <2.0)
• Non compressible vascular puncture within
past 10 days
• Recent major surgery (within 3 weeks)
• Traumatic or prolonged CPR (for more than
10 minutes)
• Recent internal bleeding (within 2-4 weeks)
• History severe chronic poorly controlled
• Hypertension
• Uncontrolled hypertension on presentation
(Systolic >180 or diastolic >110mmHg)
• Ischaemic stroke over 3 months ago
• Dementia or known intracranial pathology
• Pregnancy or recent delivery
• Reduced GCS
• Haemorrhagic ophthalmic conditions
• Active peptic ulcer or other ulcerative
conditions (i.e. Crohn’s disease)
• Advanced kidney or liver disease
• Prior Streptokinase / Alteplase / Reteplase
High bleeding risk and contraindications to thrombolysis
Consideration of imaging for source of PE and need for IVC filter
• In patients with suspected massive or high risk submassive PE, CTPA with concurrent CTV down to popliteal veins is recommended.
• Where CTV is not prospectively performed ultrasound of the lower limbs is an alternative and strongly recommended if considering major Rx (lysis, cath, embolectomy).
• IVC filter is placed in patients who have undergone surgical pulmonary embolectomy and in whom there remains significant lower limb thrombus.
• IVC filter is considered in patients with submassive PE, in whom there remains significant lower limb thrombus, particularly if it appears unstable.
• Advice on the use of TED stockings is available on the SCGH ED DVT pathway
Administration of thrombolysis for pulmonary embolism
Full dose thrombolysis
Alteplase (tPA)
> 65kg 10mg IV bolus, followed by 90mg IV infusion over 2 hours
< 65kg adjust dose so it does not exceed 1.5mg/kg; give 10mg IV bolus then the remainder of the dose over 2 hours
Half dose thrombolysis
Alteplase (tPA)
> 65kg 10mg IV bolus, followed by 40mg IV infusion over 2 hours
< 65kg adjust dose so it does not exceed 0.75mg/kg; give 10mg IV bolus then the remainder of the dose over 2 hours
Follow the Alteplase 2 hour infusion with anticoagulation with unfractionated heparin via IV infusion as per anticoagulation chart protocol.
Catheter directed thrombolysis
Alteplase (tPA) as directed by interventional radiology
19. References
1.Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic
Pulmonary Hypertension Circulation. AHA. 2011;123:1788-1830
2.Ho WK, Hankey GJ, Eikelboom JW. The incidence of venous thromboembolism: a prospective, community-based study in Perth,
Western Australia. Med J Aust 2008;189:144–47
3.Yan Z et al. Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical
Decision Support. Radiology 2016 Sep30:151985
4.Cho JHet al. Right ventricular dysfunction as an echocardiographic prognostic factor in haemodynamically stable patients with acute
pulmonary embolism: a meta-analysis. BMC Cardiovascular Disorders 2014, 14:64 dos: 10.1186/1471-2261-14-64
5.Pharmaceutical Benefits Scheme. http://www.pbs.gov.au/pbs/home
6.http://www.nps.org.au/medicines/heart-blood-and-blood-vessels/anti-clotting-medicines/for-individuals/anticoagulant-
medicines/for-health-professionals/evidence-summary/venous-thromboembolism
7.Sherwood et al. Gastrointestinal Bleeding in Patients with Atrial Fibrillation Treated with Rivaroxaban or Warfarin. J Am Coll Cardiol.
2015 Dec 1;66(21):2271-81. doi: 10.1016/j.jacc.2015.09.024
8.Indirect comparison of dabigatran, rivaroxaban, apixaban and edoxaban for the treatment of acute venous thromboembolism. https://
www.ncbi.nlm.nih.gov/pubmed/24989022
9.Sharif M et al. Moderate pulmonary embolism treated with thrombolysis (from the "MOPETT" Trial). J Cardio 2013; 111:273
10.Meyer et al, Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism N Engl J Med 2014;370:1402-11. DOI: 10.1056/
NEJMoa1302097
11.Piazza G, et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for
Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015 Aug 24;8(10):1382-92. doi:
10.1016/j.jcin.2015.04.020
12.Life in the Fast Lane www.lifeinthefastlane.com
13.Charlie’s ED www.scghed.com