Patients with pulmonary embolism presents in a wide variety of ways . Cognitive decision rules such as Wells Criteria assist in determining pretest probability of the diagnosis . Once acute pulmonary embolus is diagnosed , risk stratification can guide patient management . The strata are non-submassive ( low risk ), submassive ( intermediate-risk ), or massive ( high-risk ). Risk stratification can be done quickly on initial presentation to the emergency department by measuring the RV / LV ratio on CT angiogram of the chest . An RV / LV ratio > 0.9 indicates that the patient has RV dilation and RV dysfunction consistent with submassive pulmonary embolus . This category confers elevated risk for cardiovascular complications and calls for consideration of treatment options other than just anticoagulation alone . In addition to the CT scan , adjunctive testing can help with risk stratification , including troponin level , BNP level , ECG , and echocardiogram . Massive pulmonary embolus has historically been defined as large central pulmonary emboli with hemodynamic instability with systolic blood pressure < 90 despite fluid resuscitation and / or vasopressors , syncope , resuscitated cardiac arrest , or cardiogenic shock . Novel oral agents are rapidly supplanting warfarin as the anticoagulant of choice for these patients .
Non-Submassive Patient Submassive Pulmonary Embolus Massive Pulmonary Embolus
Definition
Treatment Recommendations
Normal RV / LV ratio with no evidence of RV dysfunction and normal levels of BNP , troponin , and EKG findings with stable vital signs .
� Standard forms of initially intravenous and subcutaneous anticoagulation .
� Novel oral anticoagulation can be considered in these patients provided they have demonstrated clinic stability with a low risk of bleeding complications .
RV / LV ratio on CT scan of greater than 0.9 and / or elevated levels of BNP , troponin , and EKG changes . The combination of an elevated RV / LV ratio and + troponin represents the highest risk submassive patient .
� Start on either IV unfractionated heparin , Lovenox , or Fondaparinux .
� For patients who may be candidates for advanced PE treatment , recommend consideration of IV unfractionated heparin to allow more strict titration of PTT ranges during advanced PE treatment .
� Furthermore , given the elevated risk of cardiovascular complications in this subset of PE patients , it is recommended that these patients be considered for advanced pulmonary embolus treatment in the form of ultrasound-facilitated , catheter-based thrombolysis ( EKOS — EndoWave Infusion catheter thrombolysis ; only FDAapproved catheter directed based thrombolysis system ). The review of available data favors and supports the safety and effectiveness of EKOS catheter thrombolysis over IV and has been shown to be superior to standard IV heparin for the treatment of patients with submassive PE .
� The protocol for both tPA infusion and heparin nomograms for EKOS catheter thrombolysis have been established within the Mount Carmel System and power plans are in place and approved by Trinity . IVC filter usage in these patients can be considered as adjunctive therapy at the discretion of the vascular interventionalist .
Arterial hypotension with systolic less than 90 despite fluid resuscitation and on vasopressors , syncope , resuscitated cardiac arrest , and cardiogenic shock .
� When considering advance PE therapies in these patients , cross-specialty collaboration is strongly encouraged .
Use of Oral Anticoagulation
Currently recommended oral anticoagulants for venous thromboembolism include warfarin and novel anticoagulant agents . We would defer to individual providers and their societal guidelines on use of oral anticoagulants .
Documentation Pulmonary Embolism Admit Power Plan and EKOS for PE Pre- and Post-Procedure . Collaboration Cross-specialty collaboration when advanced PE therapies are being considered is encouraged .
References 1 . Stein PD , Fowler SE , Goodman LR , et al . Multidector Computed Tomography for Acute Pulmonary Embolism . N . Engl J Med . 2006 , 354 ( 22 ): 2317-2327 . 2 . International Commission on Radiation Protection . Pregnancy and medical radiation . ICRP Publication 84 . Ann ICRP 2000 : 3-41 . 3 . Bourjeily G . Pulmonary embolus in pregnancy . Lancet 2010 ; 375:500-512 . 4 . Schembri GP 1 , Miller AE , Smart R . Radiation dosimetry and safety issues in the investigation of pulmonary embolism . Semin Nucl Med . 2010 Nov ; 40 ( 6 ): 442-54 . doi :
10.1053 / j . semnuclmed . 2010.07.007 . 5 . Nickoloff , E . l ., Alderson , P . O ., “ Radiation Exposures to Patients from CT : Reality , Public Perception , and Poilicy “( Commentary ), American J . Roentgenology . Vol . 177 :
285 – 287 . August 2001 .
This clinical guideline outlines the recommendations of Mount Carmel Health Partners for this medical condition and is based upon the referenced best practices . It is not intended to serve as a substitute for professional medical judgment in the diagnosis and treatment of a particular patient . Decisions regarding care are subject to individual consideration and should be made b patient and treating physician in concert .
Original Issue Date : August 2014 Revision Date : December 2016 Pulmonary Embolus 4
Draft April 13 , 2016