#1: Understanding the hemodynamic death spiral of PE
#2: Volume administration is seldom helpful, and potentially harmful
Volume management: Theory
Volume management: Evidence
Volume management: Bottom Line?
#3: Consider starting norepinephrine early to maintain an adequate blood pressure
#4: For treatment failure, consider inhaled nitric oxide
#5: Avoid intubation if possible
#6: Immediately determine contraindications to thrombolysis using a checklist
#7: For thrombolytic candidates, pursue thrombolysis early.
#8: Plan for failure: Know how to code an arresting PE patient
- The only evidence-based intervention that seems to improve mortality in massive PE is thrombolysis. The primary goal of therapy should be administration of thrombolysis as soon as possible to patients without contraindication.
- Consider early stabilization of blood pressure using a norepinephrine infusion, administered peripherally if necessary.
- Volume administration may facilitate dilation of the right ventricle and hemodynamic deterioration.
- Intubation is very hazardous and should be avoided if possible. Patients die from cardiovascular collapse, and intubation may worsen this.
- For a coding PE patient consider 50mg alteplase bolus as well as an infusion of epinephrine. Patients can do well despite requiring CPR and high dose vasopressor infusions.