EMCRIT PE Classification/Tx Algorithm
Massive PE
- PE with shock (sustained SBP < 90, other signs of shock)
- Cautious use of IVF – increases RV dilatation and worsens wall stress and ischemia
- Even some experimental evidence for improvement w/ Lasix
- High risk for periintubation arrest – have pressor ready
- Heparin gtt – questionable absorption of SQ lovenox in shock state
- PE with shock (sustained SBP < 90, other signs of shock)
- Heparin gtt – questionable absorption of SQ lovenox in shock state
- TPA – variations:
- full dose (100 mg) as bolus
- full dose over 2 hrs
- 1/2 dose (0.6 mg/kg to maximum 50 mg)
- 1/2 dose bolus + 2nd 1/2 as drip over 2 hrs
- 10 mg bolus and 90 mg over 2 or 8 hrs
- Turn off heparin gtt during TPA?
- Jeff Kline says keep TPA running
- Guidelines recommend hold heparin during TPA infusion
- Then restart as infusion w/o bolus after TPA done
- May wait until PTT returns to normal vs just restarting after heparin
- Surgical embolectomy or catheter embolectomy are other management possibilities
- Consider ECMO in still perfusing but deteriorating pt – can go on pump even after TPA if they have a perfusing rhythm
Submassive PE
- No shock but evidence of right heart strain (echo, BNP, troponin)
- No mortality benefit for thrombolysis, ? long-term functional benefit
