PE is the third leading cause of vascular mortality, after myocardial infarction and stroke. It is an enormously heterogeneous and unpredictable disease, which makes treatment difficult. As such, it should not be surprising that PE therapy remains highly controversial. For example, the new European Society of Cardiology guidelines recommend anticoagulation and watchful waiting for high-risk submassive PE (with salvage thrombolysis as needed). Meanwhile, in the United States, PE response teams (PERT teams) are typically employing more aggressive approaches to these same high-risk submassive PE patients. The use of systemic thrombolysis, interventional radiology strategies, and ECMO remain highly variable across different countries and different centers. Additional research is needed to resolve these controversies.
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The IBCC chapter is located here.
- The podcast & comments are below (the podcast is our longest yet at ~90 minutes of PE insanity! It's taking a little while, but will be out soon.)
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- PulmCrit Blogitorial – Use of ECGs for management of (sub)massive PE - March 24, 2024
- PulmCrit Wee: Propofol induced eyelid opening apraxia – the struggle is real - March 20, 2024
- PulmCrit wee: Why I like central lines for GI bleed resuscitation - March 13, 2024
Amazing review. One question I have for you which I can’t seem to find a straight answer for anywhere is, how long do you wait before you check a PTT and fibrinogen after the tPA is done (i.e., 30 minutes, 1 hour? etc…)
Hi Josh, awesome post as usual. What do you think of endotracheal Milrinone? There is this retrospective study, where patients received this after separation from cardiopulmonary bypass and responded wonderfully. (Gebhard et al. J Cardiothorac Vasc Anesth 2019;33(3):651–660. doi:10.1053/j.jvca.2018.09.016) I wonder why there isn’t more literature on the effect of iv. Milrinone in right heart failure? From a pathophysiological this should also work quite well. What are your thoughts on that? Another thing is Levosimendan. This is used quite a lot in Europe (e.g. Austria), I think you guys don’t have it in the States. There is also literature that… Read more »
Question regarding the best first line vasopressor. In the IBCC chapter covering submassive and massive PE there is reference that Epinephrine is the best first line vasopressor. It seems that we have moved more towards Norepinephrine (as referenced in the PulmCrit “Eight Pearls for the Crashing Patient with Massive PE”). Recent recommendations also seem to suggest Dobutamine as a second line agent and avoiding Phenylephrine and potentially even higher dose Vasopressin due to concerns for systemic vasoconstriction making it more difficult for an already decreased preload LV to then pump against a higher afterload. Thoughts on first line and second… Read more »
A few thoughts after reading the IBCC chapter: iv heparin: most patients are outside of the therapeutic range most of the time in the first 48h! (Acad Em Med 2020;27:117, MGH and other reputable facilities). For this reason our PERT STRONGLY RECOMMENDS not using iv heparin, unless there is a STRONG likelihood that a patient may need tPA or ECMO. Our interventionalists do not mind Lovenox. I’m not a fan of EKOS, but one reason it may help is in the patient with an occlusion (no flow-no tPA) that the catheter traverses. Also, the tPA doesn’t “dribble out”, but sprays… Read more »
Hi Josh,
If you’re in a position where you’re starting a second vasoactive medication for your sub/massive PE, are you putting in a central line for the vasopressin infusion or are you running it peripherally through a reasonably dependable IV (18-20G)?
I’m asking this from the point of view of a patient in the ED, who we are stabilising before they get to the ICU.
It’s my understanding that TNK is still not approved for PE thrombolysis. 50 mg of alteplase with a 10 mg bolus for massive PE in the setting of henodynamic instability or arrest. What would be considered a delay in treatment for administering alteplase for massive PE/what is a reasonable time to diagnosis and starting the alteplase (knowing sooner is better)? Many of us practice in settings where STAT echo is not possible and CTA is what we have available. Stop heparin if possible before thrombolytics; ever a reason to reverse heparin before alteplase?
It’s my understanding that TNK is still not approved for PE thrombolysis.