Stop That Clot
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The document discusses the management of massive pulmonary embolism (PE), which is defined as PE with systolic blood pressure ≤90 mmHg or a pressure drop of >40 mmHg for 15 minutes. It describes evaluating patients for right ventricular dysfunction using CT, echocardiogram, or biomarkers. For confirmed massive PE, initial treatment involves heparin, supportive care, and consideration of thrombolysis which reduces mortality compared to heparin alone but risks bleeding. Catheter-directed thrombolysis or surgical embolectomy are alternatives if thrombolysis is contraindicated or fails.
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- 1. Stop That Clot! Management of Massive Pulmonary Embolism Mai Bui-Duy, MD
- 5. What Makes a “Massive” PE So Massive? http://www.hindawi.com/journals/crim/2010/862028/fig1/
- 6. What Makes a “Massive” PE So Massive?
Editor's Notes
- Doc, I have… symptoms and/or signs of PE
- Definition of “massive” PE vs sub-massive (hemodynamic instability, not size of clot)
- Definition of “massive” PE vs sub-massive (hemodynamic instability, not size of clot)
- Management Strategies and Prognosis of Pulmonary Embolism Trial-3 (MAPPET-3) randomized 256 patients with submassive PE to receive recombinant tissue plasminogen activator (tPA) 100 mg over a 2-hour period followed by unfractionated heparin infusion or placebo plus heparin anticoagulation
- Objectively adjudicated short-term adverse clinical events were used as a primary outcome of this meta-analysis. These included mortality or an adverse clinical outcome defined as the occurrence of any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, use of vasopressors, thrombolysis, thrombosuction, open surgical embolectomy, or admission to the intensive care unit. Right ventricular dysfunction was used as secondary endpoint.
- Diagnosis: imaging CT
- Sometimes you can’t get to the CT scanner…
- Or may see thrombus in RA or RV or PA directly!
- Dobutamine will augment CO but may lead to arterial hypotension; may need to then support w/ phenylephrine which prevents tachycardia, which is good.
- International Cooperative Pulmonary Embolism Registry UFH: 80 IU/kg of body wt as IV bolus followed by infusion of 18 units/kg/hr LMWH: Enox 1 mg/kg q12 or 1.5 mg/kg daily
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- Our definition of clinical success required stabilization of hemodynamics, resolution of hypoxia, and survival from massive PE, as reported in each study. Also, just because one dislodges the clot doesn’t mean that it goes away; likely will travel downstream and infarct smaller areas of lung Minor complications: No therapy, no consequence or Nominal therapy, no consequence; includes overnight admission for observation only Major complications: Require therapy, minor hospitalization (<48 h); Require major therapy, unplanned increase in level of care, prolonged hospitalization (>48 h); Permanent adverse sequelae; Death
- Our definition of clinical success required stabilization of hemodynamics, resolution of hypoxia, and survival from massive PE, as reported in each study. Also, just because one dislodges the clot doesn’t mean that it goes away; likely will travel downstream and
- We compared embolectomy (when available) with thrombolysis in patients with shock and massive pulmonary embolism. 13 patients were operated on, 10 (77%) of whom survived. The inferior vena cava was routinely clipped. The 24 medically treated patients were given alteplase until systemic and pulmonary artery pressures stabilised and heparin thereafter; 16 (67%) survived. Major haemorrhage occurred in 28% of medically treated patients, but was not fatal. 1 patient had a small cerebral haemorrhage that resolved without drainage. One-fifth of the medical group had a re-embolism, which suggests that temporary caval umbrellas are indicated in medically treated patients. Thrombolysis may provide a life-saving option and a randomised trial is warranted.
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- Diagnosis: V/Q scan
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