(Originally presented by Dr Ivy Park)

Definition 

Acute Pulmonary Embolism with:

  • Sustained hypotension > 15 minutes (SBP<90mmHg or <40mmHg from baseline)
    • OR 
  • Inotropic requirement 

Mortality 

30 day mortality > 30% without re-perfusion 

Diagnosis 

  • CTPA (Gold standard)
    • Challenging for unstable patients
  • TTE (Suggestive features)
    • New RV strain
    • Increased RV size 
    • Direct visualisation of thrombus 

Treatment may be initiated based upon presumptive diagnosis in unstable patients 

Treatment 

PE Response Team undertakes MDT approach with consideration of:

  • Interventional Radiology
  • Systemic thrombolysis 
  • Unfractionated heparin
  • Surgical embolectomy 

Supportive treatment includes:

  • Preload optimisation
  • Inotropic / vasopressor support 
  • Pulmonary vasodilatation 
  • VA ECMO 

Current evidence and recommendation 

  • No high quality evidence to support one treatment over the other
  • MDT approach to determine risk/benefits of available treatment options 
  • Thrombolysis
    • Alteplase 1.5mg/kg- 10mg bolus then remainder over 2 hour
    • Ideal dose unknown. Some papers describe similar efficacy at lower doses 

Example PE Response Team Protocol

Useful Links:

LITFL – Massive PE

USC Journal – 2016