Pulseless, Massive and Submassive PE: Role of lytics

June 8th, 2010
by reuben in DVT/PE

[July 2016] Klinelab algorithm

Kline IUSM-EM PE Treatment Algorithm klinelab status 756896632051011584We should probably be lysing more PEs.

Update, Sept 2010

Piazza et al. Management of Submassive Pulmonary Embolism. Circulation. 2010;122:1124-1129.

Here we have a different definition of massive vs. submassive:

“Patients with acute PE who have normal systemic arterial pressure and preserved RV function have an excellent prognosis with therapeutic anticoagulation alone. In contrast, patients with massive PE present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest and have an increased risk of adverse outcomes, including death. Normotensive patients with acute PE and evidence of RV dysfunction are classified as having submassive PE, constitute a large population at increased risk for adverse events…”

So these authors suggest that PE+hypotension=massive=reperfusion therapy. For PE+normotension, they offer this algorithm:

So +biomarker is a requirement reperfusion. They also present a concise summary of how to lyse:

Back Top

Responses to “Pulseless, Massive and Submassive PE: Role of lytics”

  1. ACCP 2008 Guidelines.

    http://chestjournal.chestpubs.org/content/133/6_suppl/71S.full

    4.1.1. For patients with objectively confirmed pulmonary embolism (PE), we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such acute treatment. Patients with acute PE should also be routinely assessed for treatment with thrombolytic therapy (see Section 4.3 for related discussion and recommendations).

    4.1.2. For patients in whom there is a high clinical suspicion of PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).

    4.1.3. In patients with acute PE, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is ≥ 2.0 for at least 24 h (Grade 1C).

    4.1.4. In patients with acute PE, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A).

    4.1.5. In patients with acute PE, if IV UFH is chosen, we recommend that after an initial IV bolus (80 U/kg or 5,000 U), it is administered by continuous infusion (initially at dose of 18 U/kg/h or 1,300 U/h) with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity by the amidolytic assay rather than administration as IV boluses throughout treatment, or administration without coagulation monitoring (Grade 1C).

    4.1.6. In patients with acute PE, if monitored SC UFH is chosen, we recommend an initial dose of 17,500 U, or a weight-adjusted dose of about 250 U/kg, bid, with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity when measured 6 h after injection rather than starting with a smaller initial dose (Grade 1C).

    4.1.7. In patients with acute PE, if fixed-dose, unmonitored SC UFH is chosen, we recommend an initial dose of 333 U/Kg followed by a twice-daily dose of 250 U/kg rather than non–weight-based dosing (Grade 1C).

    4.1.8. In patients with acute nonmassive PE, we recommend initial treatment with LMWH over IV UFH (Grade 1A). In patients with massive PE, in other situations where there is concern about SC absorption, or in patients in whom thrombolytic therapy is being considered or planned, we suggest IV UFH over SC LMWH, SC fondaparinux, or SC UFH (Grade 2C).

    4.1.9. In patients with acute PE treated with LMWH, we recommend against routine monitoring with anti-factor Xa level measurements (Grade 1A).

    4.1.10. In patients with acute PE and severe renal failure, we suggest UFH over LMWH (Grade 2C).

    4.3 Systemically and Locally Administered Thrombolytic Therapy for PE
    4.3.1. All PE patients should undergo rapid risk stratification (Grade 1C). For patients with evidence of hemodynamic compromise, we recommend use of thrombolytic therapy unless there are major contraindications owing to bleeding risk (Grade 1B). Thrombolysis in these patients should not be delayed, because irreversible cardiogenic shock may ensue. In selected high-risk patients without hypotension who are judged to have a low risk of bleeding, we suggest administration of thrombolytic therapy (Grade 2B). The decision to use thrombolytic therapy depends on the clinician’s assessment of PE severity, prognosis, and risk of bleeding. For the majority of patients with PE, we recommend against using thrombolytic therapy (Grade 1B).

    4.3.2. In patients with acute PE, when a thrombolytic agent is used, we recommend that treatment be administered via a peripheral vein rather than placing a pulmonary artery catheter to administer treatment (Grade 1B).

    4.3.3. In patients with acute PE, with administration of thrombolytic therapy, we recommend use of regimens with short infusion times (eg, a 2-h infusion) over those with prolonged infusion times (eg, a 24-h infusion) [Grade 1B].

    4.4 Catheter Extraction or Fragmentation for the Initial Treatment of PE
    4.4.1. For most patients with PE, we recommend against use of interventional catheterization techniques (Grade 1C). In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest use of interventional catheterization techniques if appropriate expertise is available (Grade 2C).

    4.5 Pulmonary Embolectomy for the Initial Treatment of PE
    4.5.1. In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest that pulmonary embolectomy may be used if appropriate expertise is available (Grade 2C).

    4.6 Vena Caval Filters for the Initial Treatment of PE
    4.6.1. For most patients with PE, we recommend against the routine use of a vena caval filter in addition to anticoagulants (Grade 1A).

    4.6.2. In patients with acute PE, if anticoagulant therapy is not possible because of risk of bleeding, we recommend placement of an inferior vena caval filter (Grade 1C).

    4.6.3. For patients with acute PE who have an inferior vena caval filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

  2. According to a recent speaker at USC essentials, RV:LV size as seen on CT can also be used as evidence for RV dilation.

    [Credit: Sigrid]

  3. What actually constitutes RV dilatation on CT? Is there a standard, a number to look for, I.e. when dilatation becomes a concern? Thanks…

    greedylobster at
  4. There are some numbers offered in this abstract:

    http://www.ncbi.nlm.nih.gov/pubmed/9766724

    some radiologists will automatically comment on the RV whenever they report a positive PE study – what I’ve started doing is, on my CTPA request, I write “right sided pleuritic chest pain, please rule out pulmonary embolism, if PE is present, please comment on whether RV is dilated.”

Leave a Reply