Update: A more current review of this topic can be found in podcast 128
Jeff Kline is the master of all things pulmonary embolism in emergency medicine. This is a lecture he gave on fibrinolysis for pulmonary embolism. He discusses both massive and sub-massive PE.
Here is a pdf of the slides.
If you haven't already, you should also check out the AHA PE guidelines. I have a summary and the diagrams in another post.
Fibrinolysis in Pulmonary Embolism with Dr. Jeff Kline
The lecture starts with a few non-fibrinolytic points:
- Use PERC with clinical gestalt
- You can use a high-senstivity d-dimer in ALL risk groups
- Use a d-dimer with elevated cut-offs based on trimester in pregnant patients
- A high-sensitivity CTPA is the best thing we have and a negative is negative for all risk groups
Feel free to discuss any of those in the comments
In the guidelines, the definition is PE with SBP < 90 for > 15 minutes
Dr. Kline basically says that if you have an SBP < 90 at any point, the patient MUST be given fibrinolysis or you better have a good reason why on your chart.
Here are the points Dr. Kline can state definitively:
- The patient will feel better
- The clot will resolve more quickly
- There will be no increase in serious bleeding (Note in the original study, 2 patients with pre-lytic ICH were coded as complications)
What he can't say yet (but he has the largest RCT going on now) is mortality reduction
So who does he think should get lytics in sub-massive PE?
- BNP >90 or Pro-BNP >900 elevation (he states BNP is his go to marker). SENSITIVE
- Troponin positive SPECIFIC
- Echo with RV dysfunction, hypokinesis, dilation
He also states a low room air pulse ox is an indicator of needing lytics.
Choice of Drugs
Alteplase-he continues heparin during the infusion. He also feels you can just give the 100 mg as a bolus if you need to.
Tenecteplase-this is what he would want to receive if he had a PE. He gives it simultaneously with LMWH.
Mentions that lytics don't destroy all of the clot they just chew away at the big ones a bit.
For more PE stuff see the diagnosis protocol post and the PE debate insanity.