Pulseless, Massive and Submassive PE: Role of lytics

[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:

Rule out DVT: The evidence/practice gap

A meta-analysis in this week’s JAMA concludes that a negative whole-leg compression ultrasound rules out dangerous outcomes at three months in 99.3% of patients who are not anticoagulated in the interim. This is good news for emergency physicians, at least in patients whose pre-test probability for DVT is low. Unfortunately, it assumes a practice pattern that is more advanced than what is offered in most American centers. The majority of stateside radiology departments do not look at the calf in their rule-out DVT protocol. This policy is based on an outdated and dangerous belief that calf DVTs are benign.

In patients who localize to the calf, ask your radiologist to rule out DVT in the calf as well as the proximal vessels. In patients who are high risk for DVT, anticoagulate empirically; note the major bleeding risk for anticoagulation is 1.1% per year. I am concerned that JAMA readers will mistakenly assume that this paper applies to them and skip anticoagulation, repeat ultrasounds, and other strategies to reduce risk in their query DVT patients whose calves were never evaluated.

Hypercoaguable workup

Factor V Leiden
Prothrombin Level
Serum Homocysteine
Lupus Anticoagulant Panel
Type & Screen
Protein C Free antigen
Protein S total antigen
Protein C functional
Thrombin time
Functional antithrombin III

PERC rule out criteria and Wells score for pulmonary embolism


1. age < 50

2. HR < 100

3. SpO2 ? 95%

4. No unilateral leg swelling

5. No hemoptysis

6. No recent trauma or surgery

7. No prior DVT or PE

8. No hormone use


1. Clinical signs and symptoms of DVT? (+3)

2. Pulmonary embolism is most likely diagnosis (+3)

3. HR > 100 (+1.5)

4. Immobilization of ?3 days or surgery in previous 4 weeks (+1.5)

5. Previous PE or DVT (+1.5)

6. Hemoptysis (+1)

7. Malignancy with treatment in past 6 months, or palliative (+1)

Score ?4 qualifies to rule out with D dimer [JAMA 295 (2): 172-9]