UMEM Educational Pearls

Category: Airway Management

Title: Thrombolytic Therapy for Pulmonary Embolism

Keywords: Thrombolytic, Pulmonary Embolism (PubMed Search)

Posted: 6/16/2008 by Rob Rogers, MD (Updated: 10/18/2019)
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 Thrombolytic Therapy for PE

Mike Abraham and I had a very interesting PE case a few nights ago:

30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU.

Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable.

Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. 

Considerations for giving lytics to a PE patient:

  • It is within the scope of Emergency Medicine to give lytics without permission
  • If hypotensive-----give lytics
  • If there is evidence of RV dysfunction (which our patient had based on her Troponin)----give lytics
  • Other indications include severe hypoxemia (our patient's SpO2 was normal!!!), free-floating RV thrombus, and a patent foramen ovale
  • Despite the ability (in some centers) to consult Interventional Radiology for catheter-directed lytics, there really isn't data that shows benefit over peripherally infused thrombolytics: Give 100 mg tPA over 2 hours (Heparin is turned off for the drip. Currently only FDA approved regimen. Heparin is restarted without a bolus after the tPA infusion when the aPTT falls to < twice normal

References

 Tapson V, Up To Date, July 2007

Kline J, Journal of Thrombosis and Hemostasis, 2008