- Annual incidence of 60 - 70 cases / 100 000
- Please use either YEARS or Wells approach
- Please note you may use age adjusted d-dimer levels in Wells but not with YEARS criteria
Wells/YEARS approach
Rivaroxaban
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
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
Management Proven VTE
Provoked PE
Anticoagulate for 3 months (after the provoking trigger resolved).
Unprovoked PE
Increased risk of occult malignancy so:
- Ask about personal or family history of malignancy and symptoms concerning for underlying malignancy e.g. weight loss, bleeding, altered bowel habit etc
- A thorough physical exam: including breast and PR
- Ensure age appropriate screening is up to date
- Check FBC, ESR, LFT, U&E, CXR, Ca++, urinalysis and CXR
- Men > 40 - request PSA
- The need for further investigation (endoscopy, imaging etc.) should be guided by findings from the history and exam and results from the initial blood tests (ISTH 2017, NICE 2020)
- Unprovoked (SPESI 0) should be reviewed by an EM Senior and treated with an explanation of their situation, a prescription for Rivaroxaban (x3 months [15mg Bd x21days then 20mg OD x70 days]) and a referral letter to Haematology OPD for review. If in CUH, please warn the patient that the waiting list for (under-resourced) Haematology OPD in CUH may be many weeks. Please copy the GP in all correspondence