This is a lecture by Oren Friedman from the 2015 EMCrit Conference. See Oren's previous lecture on Clot Management in Pulmonary Embolism for the complete picture.
Watch the Video
See the Slides
Additional Information
- Does epoprostenol work for these patients? Not according to this small RCT [cite source='pubmed']20353588[/cite]
- NO in 4 pt case series
- If the patient codes, definitely give lytics if there are no contraindications, or so says the PEAPETT study (10.1016/j.ajem.2016.06.094)
- Pathophys of the Pulmonary Vasoconstriction (Cardiovasc Res 2000;48:22)
For More, See this Excellent Post:
- PulmCrit on Crashing PE
- Sara Crager has an amazing lecture for EMRAP subscibers
Additional New Information
Very nice 2024 review in Chest
More on EMCrit
Eight pearls for the crashing patient with massive PE(Opens in a new browser tab)
Submassive & Massive PE(Opens in a new browser tab)
EMCrit 354 – Reduced-Dose Systemic Peripheral Fibrinolysis in Massive Pulmonary Embolism
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Scott thanks for the outstanding presentation by Dr. Friedman. I love this subject and feel like pulmonary embolism should be treated with the same attention that the “code stroke” or “MI” gets in most hospitals around the country. All too often It is kinda pushed to side by clinicians as just a small PE or oh “the guy is stable so why do we need an echo.” I even had one physician give me grief over ordering an after hours formal echo on a guy who was “already diagnosed” with and PE and remarked “there is absolutely no need for… Read more »
Craig, We spoke more about EKOS in prior Oren podcast. At this stage, we have no definitive data that it is better than standard catheter directed lysis. Jeff Kline is still on the fence whether the ultrasound voodoo makes it better. The one trial of Flolan did not show benefit on RV. Nitric is still prob. the way to go if the hospital can afford it; otherwise, would go Flolan or some other Prost.
I run the PE team at Weill Cornell with Oren Friedman and Akhi Sista. Scott’s prior podcast with Oren has a flowchart of our protocol, but over all we use much more catheter directed thrombolysis than systemic TPA. The safety profile of CDT is so much better that we use systemic only for patients too unstable to go to IR (see Seattle II trial: no intracerebral bleeds in ~150 pts, caveat is was funded by device company). Regarding EKOS vs standard catheters, We agree with Jeff Kline that it’s not clear if the added ultrasound makes it better and use… Read more »
Great presentation, love the review of physiology behind massive/submassive PE.
I second the above question about the use of Flolan to improve PA pressures in PE, as we’ve had good success with it in other applications at our ICUs.
Thanks for the great presentation! I had a case at Janus General a while back that got me thinking about how to manage massive PE. It involved a patient with massive PE in obstructive/cardiogenic shock with rapid refractory atrial fibrillation and severe aortic stenosis. INR was above 2.5 without any previous meds (congestion?). Mechanical lysis or bridging therapies like ECMO/IABP were not available.
Would you have pharmacologicaly lysed this patient (with or without reversal of INR and if so with what) and how would you have handled the nasty combination of RV failure/AS/afib from a hemodynamic standpoint?
need to get the pt to make the decision, but I think you are truly obliged to lyse this patient. They already have compromised cardiac function–add in the PE and it will not go well. Don’t see any need to reverse INR. In fact they actually may need heparin as that INR doesn’t give a complete picture of anticoagulation.
I love this particular podcast, and the lecture. Are the slides available? They are not showing up above where it says “see the slides.”
Thanks,
Paul Bishop, NREMT-P, CCEMT-P
Pediatric/Neonatal Critical Care Paramedic
they are there; just need to look on a computer rather than mobile device. or I just added a link that should work on mobile
Agree with Craig above that all patients with submassive and massive PE should be followed carefully when they leave the hospital. Along with my colleagues Jim Horowitz from Cardiology and Akhi Sista from IR on our PE team we have set up a process for our patients to get seen, get followup Echo’s to evaluate for persistent pulmonary hypertension or the dreaded CTEPH– and yes i think these are two different animals. There are also a whole lot of new options ( and unanswered questions) RE long term anticoagulation that need to be considered. RE the use of other inhaled… Read more »
Hi Oren. Great presentation. Got totally caught up, though I should have done other stuff. I have been involved in patients who had arrested prehospitally or in the ER. Who were rescucitated with chest compressions and lysis…and who then bled (to death) from their pericardium, chest wall/ pleurae, liver/ spleen. I guess from a helicopter perspective this is not rare. Have you – ever – seen a patient recover from conditions like these? If yes: what did you do? Not surgical interventions, I guess!? Last time I was involved, we even tried putting the patient on peripheral VA ECMO to… Read more »
A really interesting presentation, thank you. I read with interest the above questions and Oren’s response of other inhaled agents to reduce PVR. I wonder if there is any evidence to support the use of sildenafil or similar drugs that also reduce PVR. A brief search yielded this publication which seems to support the idea but calls for more research. http://www.ncbi.nlm.nih.gov/pubmed/16450094
the hemodynamic upset potential of any of the systemic (rather than selective pulmonary) admin of these agents terrifies me
The data from the pulmonary HTN literature over the last decade suggest that Sildenafil will not drop the systemic blood pressure. The issue comes down to which is going to work faster in my opinion and which modality is more predictable. See the links below In regards to combination treatment: http://www.ncbi.nlm.nih.gov/pubmed/11926786 In regards to the absorbed affects of sildenafil –focus on the discussion– http://content.onlinejacc.org/article.aspx?articleid=1142699 I agree with you Scott that we have to be careful if we start to combine the medications. I think that either NO or flolan is the way to go…However oral sildenafil may be much less… Read more »
Yep, we know it is safe for PAH pts; reluctant to extrapolate that to RV cardiogenic shock pts from massive PE without a study looking at it. Can’t turn the oral agents off. This may indeed turn out to be a great way to go, but need data. There actually is only a single case report on a PE patient here: Inten Care Med 2006;32:452. In dogs, when used with iNO, there was indeed hypotension: PMID 18834358. I’m sticking with NO.
Good point…there are no studies really. I guess it would be hard do the study with enough power unless you had several centers..HEY we should conduct the PiNOiRVF study..Prostacylin and Inhaled Nitric Oxide in RV failure study..lol. You would have to get several big centers involved, like ARDS net. Personally, IF I had a PE, I would want to have EKOS followed by some inhaled flolan or some INO. I did find this though….seems there is a case report about PE in humans treated with inhaled prostacylin…just cant open the article. So I dont know the specifics of the case.… Read more »
not sure of your case report, but here is the RCT: PMID: 20353588
Typo in my post: “Sunned”. Meaning of course “stunned”…
Thank you for the great podcast!! I was wondering what your is on your list of absolute contraindications for systemic thrombolysis. I have checked multiple sources on this and they all vary somewhat. Also, since intubation is frowned upon in massive PE patients, what are your criteria for when you would bite the bullet and intubate the patient?
Thank You
Jim Miller DO
Emergency Medicine
Billings Clinic
Our take on the absolute contraindications include history of hemorrhagic stroke, brain mass or recent ischemic stroke, current active bleeding– the recent surgery ( most gudelines use 10 days as recent) is a sliding scale, for instance surgery on your Cspine is different than your knee. And athough not an ‘ absolute’ always consider age in weighing your decision, the Chaterjee meta analysis showed a stark dividing line in terms of increased bleeding at age >65. When to intubate is a tough one, but its like porn – ” you’ll know it when you see it.” If the person cannot… Read more »
Thank you so much!!
For intubating, make sure to have your best people available, and have pressors at bedside… consider preemptively starting some pressors before tubing.