Pulmonary Embolism Management

1. See Also
   1. Pulmonary Embolism
   2. Deep Vein Thrombosis
   3. Thrombophilia
   4. Pulmonary Embolism Risk Factors
2. Indications
   1. Deep Vein Thrombosis (DVT)
   2. Pulmonary Embolism (PE)
3. Management: Anticoagulation
   1. See Anticoagulation in Thromboembolism
   2. Consider Heparin prior to imaging in high likelihood Pulmonary Embolism
      1. Reasonable in high risk cases
      2. Lack of study data to support as standard of care
      3. Risk of adverse outcome (i.e. bleeding complications)
4. Management: General Approach
   1. Disposition
      1. Inpatient Anticoagulation until therapeutic is typical
      2. Outpatient Anticoagulation management may be considered if all of the following criteria are met
         1. Pulmonary Embolism Severity Index (PESI) Score <66 (Class 1) and
         2. Reassuring appearance with normal vital signs and
         3. Troponin normal and
         4. No signs of right ventricular strain
         5. Aujesky (2011) Lancet (2011) 378(9785): 41-8
   2. Consider Thrombophilia work-up
      1. See Thrombophilia
      2. Reserve blood for tests prior to Anticoagulation
   3. Supplemental Oxygen
   4. Bed rest is not necessary
      1. Does not prevent new or fatal PE of bleeding
      2. Trujillo-Santos (2005) 127:1631-6
5. Management: Massive Pumonary Embolism (Severe cardiovascular compromise)
   1. See Pulmonary Embolism Evaluation with Echocardiogram
   2. Indications
      1. Massive Pumonary Embolism
         1. Pulmonary Embolism and
         2. Systolic Blood Pressure <90 mmHg or >40 mmHg drop in Blood Pressure from baseline for at least 15 minutes
      2. Submassive Pulmonary Embolism (controversial for Thrombolytic use, evaluate on a case by case basis)
         1. Pulmonary Embolism and
         2. Right ventricular dysfunction (RV Strain)
            1. Serum Troponin elevation or
            2. ntBNP >900 pg/ml or (BNP >90 pg/ml) or
            3. Echocardiogram with right ventricular dilation or hypokinesis
   3. Intervention options (includes Anticoagulation as above)
      1. Thrombolytic Therapy
         1. Confirm no Thrombolytic Contraindications
         2. See Thrombolysis in Massive Pulmonary Embolism
      2. Surgical embolectomy
         1. Lower mortality and complications than Thrombolysis
         2. Gulba (1994) Lancet 343:576-7
   4. References
      1. Jaff (2011) Circulation 123: 1788-830
6. Prevention
   1. See DVT Prevention
   2. See DVT Prophylaxis
   3. See DVT Prevention in Travelers
   4. Inferior Vena Cava Filter Indications
      1. Pulmonary Embolism despite Anticoagulation
      2. Contraindication to Anticoagulation
7. References
   1. Wilbur (2012) Am Fam Physician 86(10):913-9