Podcasts · Core EM - Emergency Medicine Podcast
Episode 214: Acute Pulmonary Embolism
· Episode 214
Episode Episode 214: Acute Pulmonary Embolism
We review the diagnosis, risk stratification, & management of acute pulmonary embolism in the ED.
Hosts: Vivian Chiu, MD Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Pulmonary_Embolism.mp3
Download One Comment Tags: Pulmonary
Show Notes Core Concepts and Initial Approach
• Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli. • Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually. • Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision.” • Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy.
Clinical Presentation and Risk Stratification
• Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse. • Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever. • Chronic: Can mimic acute symptoms or be totally asymptomatic. • Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion. • High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15 minutes), requirement of vasopressors, or signs of shock → activate PERT team immediately. • Crucial Mimics: Think broadly; consider pneumonia, ACS, pneumothorax, heart failure exacerbation, and aortic dissection.
Workup & Diagnostics
• History/Scoring: Ask about prior clots, recent surgeries, hospitalizations, travel. Use Wells/PERC criteria to assess pretest probability. • Labs:
• D-dimer: A good test to rule out PE in a patient with low probability. If suspicion is high, proceed directly to imaging. • Troponin/BNP: Act as RV stress gauges. Elevated levels are associated with increased risk of a complicated clinical course (25-40%). • Lactate: Helpful in identifying patients in possible cardiogenic shock. • EKG: Most common finding is sinus tachycardia. Classic RV strain patterns (S1Q3T3, T-wave changes/inversions) are nonspecific.
• Imaging:
• CXR: Usually normal, but quick and essential to rule out other causes. • CTPA: The usual standard and gold standard for stable patients. High sensitivity (> 95%) and can detect RV enlargement/strain. • V/Q Scan: Option for patients with contraindications to contrast (e.g., severe contrast allergies). • POCUS (Point-of-Care Ultrasound): Useful adjunct for unstable patients.
• Bedside Echo: Can show signs of RV strain (enlarged RV, McConnell sign). • Lower Extremity Ultrasound: Can identify a DVT in proximal leg veins.
Treatment & Management
• Resuscitation (Reviving the RV):
• Oxygenation: Give supplementally as needed (nasal cannula, non-rebreather, high flow). • Intubation: Avoid if possible; positive pressure ventilation can worsen RV dysfunction. • Fluids: Be judicious; even the smallest amount can worsen RV overload. • Vasopressors: Norepinephrine is preferred as first-line for hypotension/shock.
• Anticoagulation (Start Immediately):
• Initial choice is UFH or LMWH (Lovenox). • Lovenox is preferred for quicker time to therapeutic range, but is contraindicated in renal dysfunction, older age, or need for emergent procedures. • DOACs can be considered for stable, low-risk patients as an outpatient.
Escalation for High-Risk PE
• Systemic Thrombolytics: Consider for very sick patients with shock/cardiac arrest (e.g., Alteplase 100 mg over two hours or a bolus in cardiac arrest). High risk of intracranial hemorrhage; weigh risks versus benefits. • PERT Activation: Engage multidisciplinary teams (usually including ICU, CT surgery, and interventional radiology). • Interventions: Consult specialists for catheter-directed thrombolysis or suction embolectomy. Surgical embolectomy can also be considered.…
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