Pulmonary Embolism (in Adults)




Approach


Major risk factors for PE

Surgery

  • Major abdominal / pelvic / knee surgery
  • Post-op intensive care

Obstetrics

  • Late pregnancy, Caesarian section
  • Puerperium

Lower limb problems

  • Fracture, Varicose veins

Malignancy

    • Abdominal / pelvic
    • Advanced / metastatic

Reduced mobility

    • Hospitalisation
    • Institutional care

Miscellaneous

    • Previous proven VTE

Management probable massive PE

Management massive PE Flow diagram

Massive PE likely if:

  • Collapse/hypotension and
  • Unexplained hypoxia , and
  • Engorged neck veins , and
  • Right ventricular gallop (often)

Thrombolysis

Alteplase dose

For patients >65kg a total dose of 100mg should be administered in 2 hours as follows:
10mg as an IV bolus over 1-2 minutes, followed by an IV infusion of 90mg over 2 hours

For patients <65kg the total dose should not exceed 1.5mg/kg as follows:
10mg as an IV bolus over 1-2 minutes, followed by remainder of dose as an IV infusion over 2 hours

Post thrombolysis

  • Thrombolysis should be immediately followed by unfractionated heparin
    • Give bolus UFH 5000 units (unless earlier/on therapeutic LMWH)
    • Then 1000 U per hour and ajust to aPTT at 2.0-2.5 times the upper limit of normal
    • If already given LMWH, delay IV heparin for 12 hours and reassess (with aPTT)
  • Contraindications to thrombolysis should be reconsidered in life-threatening PE
  • Out -of-hospital cardiac arrest patients with PE rarely recover.
  • Thromboilysed cases should be discussed with the respiratory team on call.


Content by - Dr Íomhar O' Sullivan 22/09/2003. Based on the British Thoracic Society Guidelines 2003. Reviewed by Dr ÍOS 04/03/2007, 10/03/2009. Lasts review Dr. √ćomhar O' Sullivan 25/03/17.