•Clinical symptoms of DVT (leg swelling, pain with palpation): 3
•PE more likely than other diagnoses: 3
•HR >100: 1.5
•Immobilization (≥3 days) or surgery in the previous 4 weeks: 1.5
•Previous DVT/PE: 1.5
•Hemoptysis: 1
•Malignancy: 1
📝ED #order for suspected PE
#Episode_1
▪️Imp: suspected PE
▪️Cond: emergency
▪️Diet: NPO
▪️Act: CBR and bed sides up
▪️C.V.S q1h
▪️CM and POM
▪️IV line fix
▪️oxygen therapy with nasal cannula to maintain sat>90
▪️IV fluid therapy with crystalloid if indicated
▫️For those who require hemodynamic support, (IVF; 250 to 400 mL of normal saline) rather than larger volumes ,Vasopressor therapy should be initiated if perfusion fails to respond to IVF.
▪️ECG stat (Sinus Tach, inverted T v1-v4, RV strain, incomplete RBBB, s1q3t3, etc)
▪️CXR (to look for an alternative cause)
*it is not necessary if a CTPA is planned.
▪️CBC, BUN, Cr, ESR, lactate, LDH, AST, ALT, PT, PTT, INR,VBG, BNP, Trop
*Unexplained hypoxemia in the setting of a normal chest radiograph should raise the clinical suspicion for PE.
▪️Echocardiography (not routinely)
*Echocardiography can diagnose PE when thrombus is visualized in the proximal pulmonary arteries(rare) phenomenon.
*it is most useful for prognostic purposes in patients with confirmed PE (eg, new RV strain and RV thrombus are poor prognostic indicators)
▪️Lower-extremity ultrasound with Doppler(not routinely)
*A new diagnosis of DVT in the setting of symptoms consistent with PE is highly suggestive, although not definitively diagnostic, of PE.
🔹 based on the Wells(for diagnosis )
▪️Wells<2, consider PERC
*if PERC(+), order D-dimer
▪️Wells(2-4), check D-dimer
*if D-dimer>500,order imaging
▪️Wells>4
▫️imaging:
-CTPA if GFR>60
-ventilation perfusion scan if GFR<60 or in pregnancy .
▫️order anticoagulant (LMWH) if no contraindications
🔹based on hemodynamic stability (for treatment of suspected PE)
▪️Unstable patient(ie, high-risk or "massive" PE, sustained hypotension)
▫️First step is resuscitation: Resuscitation involves any combination of respiratory (oxygen, noninvasive or invasive mechanical ventilation) and hemodynamic support (IV fluids, vasopressors)
*if unstable after resuscitation, then start Thrombolytics if no contraindications.
▫️Amp tPA (Alteplase) 50-100mg IV over 2hr
▪️Stable patient (or unstable that resuscitated ), decide based on the wells(clinical suspicion) and availability of diagnostic testing for initial anticoagulant (if no contraindication)
▫️Wells<2
* diagnostic evaluation take >24h: start anticoagulant
* diagnostic evaluation take <24h: don’t start anticoagulant
▫️Wells(2-4)
* diagnostic evaluation take >4h: start anticoagulant
* diagnostic evaluation take <4h: don’t start anticoagulant
▫️Wells>6
* start anticoagulant
▪️Amp Enoxaparin 1mg/kg SC q12h
*Contraindications : Severe renal impairment (CrCl <30 mL/min), Patients with morbid obesity or anasarca may have poor absorption
Or
▫️Amp Heparin 80 units/kg bolus; then 18 units/kg/hr continuous infusion
*Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
*Contraindications: Previous history of HIT ,Use with caution in patients >60yo
🔹Appendix:
▪️Contraindication of anticoagulation(table)
*Patients at high risk of bleeding are considered as having a contraindication to anticoagulation;
*patients at low risk of bleeding are considered as having no contraindications to anticoagulation.
*Patients at moderate risk of bleeding should be considered for anticoagulation on a case-by-case basis.
▪️Contraindication of thrombolytic, wells, risk of bleeding( table)
▪️indications for thrombolytic therapy in venous thromboembolism:
High-risk (massive) PE (ie, presence of hypotension related to PE)
▫️Potential indication:
Patients with severe right ventricular dysfunction due to PE (ie, intermediate risk PE),
Presence of severe hypoxemia (particularly in those with a contribution from concomitant cardiopulmonary disease),
Patients with acute PE who appear to be decompensating but are not yet hypotensive, Extensive clot burden.