Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE). PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum. Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics. Anand argues for the use of thrombolytics. Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time. Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve. Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs. Iain takes a different approach in his reply. Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these. In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song! Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell For more like this, head to our podcast page. #CodaPodcast

11. harm

12. got lytics?

14. shared decision making

16. Take Home Points

17. @EMSwami

19. Should we
Thrombolyse Patients
with Submassive PE in
the Emergency
Department?
Dr Iain D M Beardsell MBChB FRCEM
Consultant in Emergency Medicine and Prehospital
Emergency Medicine
University Hospital Southampton
UK

20. What is A Pulmonary
Embolism?
• Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has traveled
from elsewhere in the body through the bloodstream (embolism).[1] Symptoms may include shortness
of breath, chest pain particularly upon breathing in, and coughing up blood.[2] Symptoms of a blood
clot in the leg may also be present such as a red, warm, swollen, and painful leg.[2] Signs include low
blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever.[3] Severe cases can
lead to passing out, abnormally low blood pressure, and sudden death.[4]
• PE usually results from a blood clot in the leg that travels to the lung.[1] The risk of blood clots is
increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, pregnancy,
obesity, and after some types of surgery.[5] A small proportion of cases are due to the embolization of
air, fat, or amniotic fluid.[6][7] Diagnosis is based on signs and symptoms in combination with test
results. If the risk is low a blood test known as a D-dimer may rule out the condition. Otherwise a CT
pulmonary angiography, lung ventilation/perfusion scan, or ultrasound of the legs may confirm the
diagnosis.[8] Together deep vein thrombosis and PE are known as venous thromboembolism (VTE).[9]
• Efforts to prevent PE include beginning to move as soon as possible after surgery, lower leg exercises
during periods of sitting, and the use of blood thinners after some types of surgery.[10] Treatment is
typically with blood thinners such as heparin or warfarin.[11] Often these are recommended for six
months or longer.[12] Severe cases may require thrombolysis using medication such as tissue
plasminogen activator (tPA), or may require surgery such as a pulmonary thrombectomy. If blood
thinners are not appropriate a vena cava filter may be used.[11]