UMEM Educational Pearls

Moderate to High-Risk Pulmonary Embolism

In stable patients, call your local PE Response Team (PERT) for advice. The UMMC PERT team is available for any patient in the region and can be contacted through Maryland Access Center.

UMMC PERT stratifies by BOVA (with lactate criteria), CTA imaging, and patient physiology/history. For the consult, we will use the patients most recent vitals, their ROOM AIR sat if available, presence of RV dysfunction on echo/CTA, recent lactate, troponin, BNP, bedside/formal echo, and HPI.

Broad management recommendations for moderate or high-risk patients

• Presence of signs and symptoms of RV failure are usually the most concerning findings (cor pulmonale, RV:LV ratio > 1, hypoxia, etc)
• Fluid should only be given to optimize preload, usually guided by bedside echo. Start with aliquots of 250mL or 500mL. Fluid-restrictive strategy is usually preferred.
• First line pressor is norepinephrine. Epinephrine should be used for evidence of ventricular dysfunction
• We recommend inhaled vasodilators should be used in persistent hypoxemia or evidence of RV dysfunction. (This can be done via high-flow nasal cannula. Author editorial: every ED in America with HFNC should have the ability to do this. This alone can save a life.)
• Recommended SPO2 goal is >90% in absence of other lung pathology. AVOID positive pressure ventilation if at all possible.
• If intubation is necessary, optimize pressors, inotropes, and bronchodilation beforehand and have code drugs ready!
• Anticoagulation with unfractionated heparin in high risk patients. Our typical recommendation is 48-72 hours of unfractionated heparin in moderate risk patients as well, but DOACs are also an option. DOACs are not recommended in high risk patients currently.
• In hemodynamically unstable or coding patients without rapid access to VA-ECMO, we usually recommend thrombolytics in all patients with high suspicion for PE and without absolute contraindications (see below - PERT team can help guide this decision if there is time).
• See Pearl from 8/23/2023 for excellent summary of fibrinolytics and CPR in PE.
• IMPORTANT: While a patient may not be a candidate for therapy at the moment, it is important to clarify with PERT if they WOULD BE if they experience a degradation in circulating biomarkers or physiology (most patients would). Please pass this along to your admitting teams as well!
• Typical recommendations are for anticoagulation and repeat echocardiography in 48-72 hours to detect any worsening in RV function. 
• When in doubt, call your local PERT team!

PERT Acceptance for Transfer to UMMC/CCRU

• The primary decision will be whether this patient is a candidate for mechanical therapy (catheter-based or VA-ECMO). We are also evaluating for enrollment in the HI-PEITHO trial (see below). For patients who are candidates for mechanical therapy, the CCRU attending may bring on the entire PERT team: Cardiac Surgery, MICU, and Interventional Radiology (day 1-7 each month) or Vascular Surgery (day 8 or after each month).

See below for more information.

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Definitions of RV dysfunction

• TTE - RV/LV ratio >0.9, sPAP >30, RV end diastolic diameter >30mm, RV dilation, or free wall hypokinesis
• CTA - RV/LV ratio > 1

Absolute Contraindications to Fibrinolytic Therapy in Pulmonary Embolism

UMMC Relative Exclusion Criteria for VA ECMO for PE

• Age > 75
• Known metastatic cancer
• Cirrhosis
• O2 dependent COPD/ lung disease
• Severe dementia/ nursing home dependence

HI-PEITHO (NCT04790370) “is a prospective, multicenter RCT comparing Ultrasound-facilitated catheter-directed therapy (USCDT) and best medical therapy (BMT; systemic anticoagulation) with BMT alone in patients with acute intermediate–high-risk PE.”

Inclusion Criteria

• Two or more of: 
  • HR >100
  • SBP<110
  • RR>20 or SPO2<90% RA
• RV:LV > 1.0 on CTA
• Troponin elevated