You
are called by the ED for a 56 year old female who is about 24 days post op from
a Left THR, brought back to the ED from rehab with dyspnea and noted to be in
severe distress. Saturating about 92% on 15L high flow cannula.
Tachycardic @ 115. BP is ok 137/64. Chest xray was normal. EKG was ST with no
ischemia. Troponin mildly elevated at 0.945. She appears clammy and
diaphoretic. Lactate was 2.4. Stat CT angio was completed in ED with B/L acute
PE involving proximal pulmonary arteries with extension into the segmental
arteries. RV:LV ratio was 1.1. ECHO has been ordered. You note the pt was
taking 162mg BID aspirin for extended spectrum DVT prophylaxis post operativly.
What are your next steps?
This patient would be considered thermodynamically unstable due to the respiratory distress requiring 15L on high flow, tachycardia as well as the autonomic symptoms of diaphoresis and clamminess. With the enlarged right ventricle it would be appropriate to administer tPA. Afterwards a heparin drip would be started. The patient's surgery is more than 14 days ago and is not a contraindication to tPA. The patient would need to restart their aspirin use after 24 hours of tPA administration has passed.
ReplyDeletehttp://www.uptodate.com/contents/intravenous-thrombolytic-therapy-for-acute-ischemic-stroke-therapeutic-use?search=tpa+contraindications&source=search_result&selectedTitle=1%7E150#H548390
http://www.uptodate.com/contents/treatment-prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults?search=pe+treatment&source=search_result&selectedTitle=1%7E150
Andrew Lee
DeleteThis patient appears to have a submassive PE without systemic hypotension, right ventricular dilatation, the size of the left ventricle, severe hypoxia, and elevated troponin. She would benefit from TPA administration in the ED because it has been shown to be associated with a worse prognosis than mild or no RV dysfunction. She would then transfer to the unit for close monitoring post tPA administration. After the 24 hour window, she would be transitioned to either heparin drip or a NOAC agent. Would also monitor her respiratory status, obtain an ABG and treat as indicated.
ReplyDeleteIndication for TPA is for persistent hypotension or shock (SBP < 90) from a PE. For hemodynamically stable patients, possible indications are severe/worsening RV dysfunction, CPA due to a PE, or excessive clot burden. She does show signs of right heart strain with a RV:LV ratio of 1.1. It should normally be 0.6:1. TPA should be considered in this patient since RV dysfunction is associated with a worse prognosis in an PE. Per uptodate (https://www.uptodate.com/contents/thrombolytic-fibrinolytic-therapy-in-acute-pulmonary-embolism-and-lower-extremity-deep-vein thrombosis?search=PE+treatment+tpa&source=search_result&selectedTitle=1%7E150), “further randomized trials are needed to identify subpopulations of patients with RV dysfunction where the benefits in mortality clearly outweigh the risk of hemorrhage before it can be routinely used to treat hemodynamically stable acute PE with RV dysfunction.”
ReplyDeleteLooking at the patient condition,she has severe pulmonary hypertension secondary to sub massive pulmonary embolism that put a lot of strain on right ventricle and it size become equal to left ventricle. Patient is also in severe respiratory distress despite of high amount of oxygen supplementation.TPA is the treatment of choice here and if it fails ,the next step is surgical thrombectomy because the right ventricular strain has very poor outcome with PE.
ReplyDeleteThis patient has a post-operative pulmonary embolism and requires anticoagulation which should have already been started given the high suspicion for PE before even getting imaging, and tPA now that we have all the results. This PE would be defined as submassive because her blood pressure is maintaining with an SBP > 90. She has signs of RV dysfunction with elevated troponin and increased RV size based on the RV:LV ratio. No all submassive PE requires anticoagulation but based on the 2 above findings she would be a candidate.
ReplyDeletePEITHO trial, MOPETT trial
Life in the fast lane
References from our discussion
ReplyDeletehttps://emcrit.org/pulmcrit/submassive-pe-peitho/
https://lifeinthefastlane.com/ccc/thrombolysis-submassive-pulmonary-embolus/