Massive Pulmonary Embolism March 2018 | by EMauthor SYMPTOMS AND SIGNS •Massive PE highly likely if there is: •Collapse/hypotension and oUnexplained hypoxia and oEngorged neck veins and oRight ventricular gallop (often) MANAGEMENT •Oxygenate! •Adequate analgesia for pleuritic pain: IV ketorolac 30mg or iv diclofenac 75 mg in 100 ml normal saline •If right atrial pressure (i.e. JVP) elevated, assume patient is pre-load dependent and avoid diuretics.
Thrombolysis •If life-threatening features (right heart failure, shock) present, give alteplase 50 mg IV as bolus injection •Failure to respond to alteplase is an indication for emergency direct thrombolysis, catheter thrombo-embolectomy or pulmonary embolectomy. Contact interventional department/interventional radiologist and cardiothoracic surgeon to discuss. •If patient stable (with no systemic hypotension), consider thrombolysis if they have echocardiographic evidence of right ventricular dysfunction or free-floating right ventricular thrombus oIf thrombolysing, give alteplase 10 mg by IV injection over 1–2 min, followed by 90 mg by IV infusion over 2 hr (max 1.5 mg/kg in patients weighing <65 kg) oIf not thrombolysing, anticoagulate If there are contraindications to giving alteplase or anticoagulation, a consultant emergency physician, or registrar must make a decision as to which carries most risk – possible complications of therapy, or embolism. Post-thrombolysis •After thrombolytic therapy has ceased, wait until APTT ratio has fallen below 2 before commencing or recommencing anticoagulation as follows: oin all patients, start with unfractionated heparin with no loading bolus – see IV unfractionated heparin guideline. In pregnant women, monitor anti-Xa concentration as a guide to dosage adjustment oif pregnant, change unfractionated heparin to clexane when APTT stable oif not pregnant, start rivaroxaban
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