060. Thromboembolism

PERC

(Kline, Annals, 2013): Reviewed 1880 pts with PE diagnosed; 114 were PERC negative (6.1%). Looked for signs/symptoms that would make PE more likely to be PERC negative. Only 3 variables that had true difference: pleuritic chest pain, pregnancy, and postpartum with pleuritic chest pain being the most significant. Lower mortality if PERC negative (no deaths at 30 days). Concluded pleuritic chest pain likely due to distal segment ischemia and lower risk for morbidity/mortality. Kline has stated during lectures he would almost consider these patients to likely have sub segmental PEs and don’t need treatment anyway.

Outpatient Management

Aujesty et al, 2011: 330 pts, used PE Severity Score of 1 or 2 (< 86 points), excluded O2 sat < 90%, SBP < 100, requiring IV narcotics, creatinine clearance < 30, extreme obesity > 150kg (basically complications with anticoagulation). 14 and 90 day outcome were the same for mortality and repeat VTE, slightly increased major bleeding risk in outpatient group, though not significant. Gave lovenox 1mg/kg SC BID + Warfarin 5mg PO daily, f/u in 3 days.

Outpatient

Clinical Cases

Annals of EM: Massive PE with echo showing RV dilation, septal bowing. CT showed contrast reflux which is 98% specific for right sided heart strain. EKG showed t-wave inversions in inferior/anterior leads. Two videos of bedside echo.

References

Annals of EM, Kline, 2013, Clinical Features of Patients with PE and a Negative PERC Rule Result

PE Management as an Outpatient, Ryan Knapp, 2015 Managing Medical Emergencies, EMedHome

TAPSE: Echo finding you can calculate with M-mode that basically assess the EF of the right ventricle. Basically look at the function of the tricupsid valve against ventricle pressure. Looking for regurg as well. Looking for PA pressure being large in large PE.

Massive PE: PE with patient in hypotensive or shock.

Submassive PE: normotensive with RV dysfunction.

High Risk Features: Hypoxia, ECG (RBBB, S1Q3R3, Twave inversion), Elevated troponin, Elevated BNP, Abnormal Echo (RV dilation, RV hypokinesis, paradoxical septal motion D-sign).

Inhaled Nitric Oxide (decreases pulmonary vasculature resistance) – new treatment being done by Kline, study results still pending.

Diuretics – 40mg q4hr if urine was lower than < 0.5mL/kg. Study looked at submassive PE. Improvements in both BP and shock index with lasix compared to normal saline.

Intubation: positive pressure ventilation increases pulmonary vascular resistance so be ready for pressors. Increased resistance is the reason PE patients crash or go into shock in the first place.

With hypotensive patients, go for Levophed very quickly after considering given normal saline. They are not very fluid-responsive (they dont need more preload).

tPa: MOPETT: 1/2 dose tPa submassive PE with no significant bleeding, RV dysfunction resolved.  PEITHO: 1000 pts, NNT 33, NNH 55. 2014 JAMA Metaanalysis: NNT 59 to prevent mortality, NNH 18 for major bleeding. Age > 65 NNT: 64, NNH 18. Intermediate risk PE NNT 65, NNH 18.

SEATTLE II Study: catheter directed tPa. no control. Mainly submassive patients. Looked like RV dysfunction. Looked at CT findings for RV dysfunction. Drip in tPa for about 12 hours. Most placed by cardiologist. Bleeding rate: no ICH, 1 major bleeding at groin site. Appears safe, early hemodynamic improvement, submassive PE pts die infrequently.

Recent Advances in the Management of Massive & Submassive PE, Mark Favot, 2016 MCEP Critical Care in the ED, eMedHome.

060. Thromboembolism

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