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
POCUS:
- RV wall hypokinesis
- RV dilation
- RA dilation
- Paradoxical septal systolic motion and dilated IVC
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 adjust 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
- Thrombolysed 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:
- Seek PM Hx or FHx of cancer & concerning symptoms e.g. Wt. loss, 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 (before PR exam)
- 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, TnI normal) patients should be reviewed by an EM senior. After a thorough explanation, a joint patient-physician decision to continue management at home may be made. These patients require 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 may be many weeks. Please copy the GP in all correspondence
sPESI
simplified PE Severity Index
| sPESI criteria | Points |
|---|---|
| Age > 80yrs | 1 |
| Hx cancer | 1 |
| Chronic cardiopulm. disease | 1 |
| sBP<100 | 1 |
| AHR ≥110 | 1 |
| Sats<90% | 1 |
Clinically well patients with a "0" sPESI score and negative TnI can safely be managed in an outpatient setting.
PE "excluded"
For those "PE negative" discharged patients,please advice to seek help if symptoms continue (CTPA false Neg rate = 1.1%, many other [e.g. ACS] need Mx).