Cite this post as:

Scott Weingart, MD FCCM. EMCrit 308 – Risk Stratification and Treatment of Pulmonary Embolism (PE) 2021 – Is the PERT Wilted?. EMCrit Blog. Published on October 7, 2021. Accessed on December 2nd 2021. Available at [https://emcrit.org/emcrit/pe-rx-pert/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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Bo Thomas
Bo Thomas(@bothepharmer)
1 month ago

At my little hospital we usually EKOS or half dose TPA for sub massive PE but we use the MOPETT trial protocol of TPA 10mg push followed by 40mg over 2 hrs. Is there a trial that uses the 50mg over an hour that is suggested here? Thanks

What's Your Job?
ICU/ID Pharmacist
Scott Gallagher
Scott Gallagher(@docgliv)
1 month ago
Reply to  Bo Thomas

At our small/rural hospital, we have chosen the following lytic options for massive PE:

  1. Cardiac arrest: alteplase 50 mg over 2min
  2. Unstable: alteplase 20 over 2 min, followed by 80 mg over 2 hours
  3. Stable: 100 mg over 2hours.

I think TNK would be easiest in arrest scenario, such as I has few months ago, but pharmacy was most comfortable with alteplase.

Scott Gallagher

What's Your Job?
Rural EM physician
Chris Colanero
Chris Colanero(@colanero88gmail-com)
1 month ago

Scott, in your experience have patients who fell into the massive super sick category responded similarly to the 50mg over 1hr vs peri-code 50mg over 5 mins? When the ICU docs at my hospital encounter these patients they favor giving lytics as fast as possible to attenuate the hemodynamic instability. Also any thoughts on using your 25mg over 6 hrs in the same massive sick category regardless on bleeding risk?

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Pharmacist
James Caffrey
James Caffrey(@jcaffrey)
1 month ago
Reply to  Chris Colanero

Huge saddle embolism ,no rv strain on cta ,trop slightly slightly elevated norm tacky to 110
My situation last night could not make it to end of podcasts despite being a long term member and signing up again Just gave 80 units/kg heparin and dripped. I am in an underserved critical access er no formal echo nvm but thanks finally made sign up stick

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Er physician
James Caffrey
James Caffrey(@jcaffrey)
1 month ago

James A Caffrey DO
Crit access er physiciann
Love the podcast and membership
Plz remedy subscription/podcast/ sign up
Cluster

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Er
Nils Nickel
Nils Nickel(@npnickel)
1 month ago

Hi! Great summary of the complicated PE universe.

Could you please comment on the hemodynamic stable, severely hypoxic patient?
What is your treatment approach? How much lysis do you give?
Thanks,

Nils

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Critical Care MD
Jakub Baszczuk
Jakub Baszczuk(@jacobi)
4 days ago

I’ve encountered case reports about using a Swan-Ganz catheter as a way of catheter directed thrombolysis in high bleeding risk patients when commercial dedicated kits or personnel were unavailable. I personally think it is a great option to give low dose alteplase directly into pulmonary artery until we obtain evidence that periprheal low-dose infusions are noniferior. What do you think about it?
Also might be the best use for Swan-Ganz catheters in the bedside echo era.

Link to the case report:
https://www.annalsofvascularsurgery.com/article/S0890-5096(17)30675-1/fulltext

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Med Student
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