Pulmonary Embolus pondering

A 52 y.o. bricklayer is transferred from another hospital with an acute episode of dizziness, palpitations and tachycardia. 2 days ago he had bilateral total knee replacements for osteoarthritis.Observations on arrival: P 120, BP 130/75, RR 22, SpO2 88% room air, 98% 4 litres via nasal prongs.ECG CTPA Bedside echo in EmergencyNormal LV, dilated RV with moderate impairment, septal paradox (bowing RA septum towards left).Troponin I (high sensitivity) 4410 ng/LThis man has acute Pulmonary Embolus (PE)His ECG demonstrates a normal axis, tachycardia and SI QIII TIII (see also ECG changes in PE).His CTPA demonstrates an extensive clot in the right PA (and subsegmental clots on the left).There is evidence of right ventricular strain on echo and biochemical evidence of cardiac damage.What are the treatment options? Does he need removal of the clot by some means?Possible treatment options in acute PE:Low molecular weight heparin and close observationUnfractionated heparin infusionIVC filterThrombolysisThrombectomyCatheter directed therapyQuality evidence to inform the treatment of PE causing cardiovascular instability has been sparse for many years. The initial study published in 1995 examining the role of thrombolysis for ‘massive’ PE was stopped prematurely after n=8 were recruited and all subjects in the control (heparin) group died. This was then the basis of our practice for many years. Whilst it is persuasive of the role of thrombolysis in ‘massive’ PE it does not repr...
Source: Life in the Fast Lane - Category: Emergency Medicine Authors: Tags: Respiratory PE PEITHO PTE Pumonary Embolus tenecteplase thrombolysis Source Type: blogs