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Eight pearls for the crashing patient with massive PE

Literature on massive PE focuses mostly on how to deal with the clot while less attention is spent on other aspects of management. This post will focus on such aspects, especially hemodynamic resuscitation of massive PE. There is nearly no clinical data, forcing us to extrapolate between limited data, hemodynamic theory, and experience. This post may be considered a working theory at best.

#1: Understanding the hemodynamic death spiral of PE

To save PE patients, first we must understand how they die. Death is due to hemodynamic collapse rather than hypoxemia. The physiology involves RV dilation with impairment of left ventricular filling and hypoperfusion…

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 We call it massiiiiiiivve. PE at St Emlyn’s

What does ‘massive’ even mean? It’s certainly a crude word to describe the complex pathophysiology of a serious disease.

Articles of Interest

The Critical Pulmonary Embolism Patient

In massive PE, half dose thrombolytics appears to be as effective as full dose thrombolytics with less bleeding...rt-PA 50mg over 2 hours has shown similar efficacy to 100mg over 2 hours in clinical outcomes with a better safety profile (less bleeding).

Hemodynamically Unstable Pulmonary Embolism

A pulmonary embolism (PE) that results in hemodynamic compromise and end-organ hypoperfusion. The physical size of the PE does not differentiate a PE as massive or submassive but rather it is the patients physiologic response to the clot(s).

Management of patients with high-risk pulmonary embolism: a narrative review

High-risk PE is a life-threatening disorder associated with high mortality and morbidity. Most deaths in patients with shock occur within the first few hours after presentation, and rapid diagnosis and treatment is therefore essential to save patients’ lives. High-risk PE is an indication for thrombolytic therapy but has the potential for circulatory collapse and is therefore often a contraindication to thrombolysis.

Pulmonary Embolism Interventions

Pulmonary embolism interventions include catheter-directed thrombolysis, mechanical thrombectomy, & surgical embolectomy. Catheter directed thrombolysis and mechanical thrombectomy are alternative treatments for patients who do not respond well to systemic anticoagulation.

Pulmonary Embolism Treatment Options

We now have way too many treatment options for sub-massive and massive pulmonary embolism (PE) patients who aren’t coding in front of you. How do you decide which one is right for your patient?

Pulmonary Embolism: Management of the Unstable Patient

In the emergency department, we are responsible for identifying and treating life-threatening conditions. When a patient presents with acute onset dyspnea, chest pain, syncope, or hemoptysis, the diagnosis of pulmonary embolism (PE) often comes to mind; however, PE may escape prompt diagnosis when the clinical signs and symptoms are not as specific.

Submassive & Massive PE

Don't delay thrombolysis if this is an option. Thrombolysis is the only intervention which is evidence-supported to improve mortality in these cases. All other interventions (pressor, inhaled vasodilators, etc) are merely intended to stabilize the patient until thrombolysis can be performed.

Submassive PE 2017: Getting ’em off the cliff

If our goal from thrombolysis is merely to avoid PEA arrest, all we need to do is reduce the pulmonary pressures somewhat (not normalize them). This may be achievable with lower doses of alteplase than have been used historically, with a superior safety profile.

The Argument for Systemic Thrombolytics in Submassive Pulmonary Embolism

Pulmonary embolism clearly exists on a spectrum from the urgent end being the sub-segmental clots with mild symptoms to the peri-arrest (or arrested) massive PE. In between there are thousands of shades of severity. We define submassive PE as any embolism with right ventricular strain.

Thrombolytics for Submassive Pulmonary Embolism

The use of thrombolytic therapy in hemodynamically stable patients with signs of right ventricular (RV) dysfunction – i.e. “submassive” PE – is highly debated. The guidelines vary widely in the their recommendations, from firmly stating “Do not offer pharmacological systemic thrombolytic therapy to patients with PE and haemodynamic stability” (NICE), to noting that there is insufficient evidence to make recommendations (ACEP), to clearly recommending thrombolysis when there is evidence of RV dysfunction or elevated cardiac biomarkers (AHA).

Treatment of Submassive Pulmonary Embolism (PE): Full Dose, Half Dose, or No Dose?

Submassive pulmonary embolism (PE) is responsible for approximately 20% of all PEs. Although the in-hospital mortality has been reported as about 5%, there is significant morbidity associated with this diagnosis such as chronic pulmonary hypertension, impaired quality of life, persistent right ventricular disfunction, and recurrent venous thromboembolism.

Resources

EM Sim Cases

The management of massive pulmonary embolism is one that requires rapid action and decisive decision-making, often based on less information than one would like. This case highlights several key features of the management of a massive PE...

PERT Consortium

The Pulmonary Embolism Response Team (PERT) Consortium was developed after the initial efforts of a team of physicians at Massachusetts General Hospital. The PERT Consortium™ intends to guide and influence pulmonary embolism (PE) care and research in institutions across the U.S. and will be the driving force behind increased survival rates and the future of PE treatment.