PE

Massive

• Sustained hypotension
(<90 SBP x 15 minutes or inotrope use)
• Pulselessness
• Persistent Profound Bradycardia
(<40 bpm with s/s shock)

Submassive: RV dysfunction or Myocardial necrosis

Acute PE without hypotension but with:

RV dysfunction:

• RV dilatation RV:LV diameter >0.9 in A4C/CT or RV systolic dysfxn in echo
• BNP >90 pg/mL or NT pro BNP >500
• ECG: (new RBBB, anteroseptal STE, STD or TWI)

Myc Necrosis: TnI >0.4ng/mL, TnT >0.1

Low-risk PE: not massive, not submassive

Massive: heparin + alteplase (100mg x 2 hrs IV or in cardiac arrest: 50mg IV bolus then another 50mg IV bolus after 15 mins if no ROSC)

Submassive: heparin +/- alteplase

*alteplase if shock/respiratory distress or mod-severe respiratory distress

shock or respiratory distress

• <90mmHg
• SI >1
• SaO2 <95% with Borg score >8
• AMS
• appearance of suffering

mod-severe respiratory distress

• RV hypokinesis, interventricular septal shift or bowing, or est. RVSP >40 mmHg
• clearly elevated cardiac markers
, TnT above borderline, BNP >100 pg/mL or NTpBNP >900

Low-risk: clexane 1mg/kg or heparin

Thrombolysis c/i:

Absolute c/i

- prior ICH

- known intracranial CVD (AVM)

- known malignant IC neoplasm

- ischaemic stroke within 3 months

- suspected aortic dissection

- active bleeding or bleeding diathesis

- recent surgery encroaching on spinal canal or brain

- recent significant closed-head or facial trauma with radiographic evidence of bony fracture or bony injury

Relative c/i

>75yo

- use of anticoagulation

- pregnancy

- non compressible vascular punctures

- traumatic or prolonged CPR (>10 minutes)

- recent internal bleeding (within 2-4 weeks)

- hx of chronic, severe, and poorly controlled HTN

- severe uncontrolled HTN on presentation >180/>110)

- dementia

- remote (>3 months) ischaemic stroke

PE Algorithm

Circulation 2011 -- Management of Massive and Submassive PE, Iliofemoral DVT, and Chronic TE Pulmonary Hypertension

- major surgery within 3 weeks