What is the treatment for pulmonary embolism under a paramedic scope of practice?

From the Guidelines

The treatment for pulmonary embolism under a paramedic scope of practice should focus on supportive care, including continuous ECG and blood oxygen saturation monitoring, and establishing intravenous access during transfer, as recommended by the Acute Cardiovascular Care Association (ACCA) of the ESC 1. When managing patients with suspected pulmonary embolism, paramedics should prioritize the use of clinical prediction scores to determine the likelihood of pulmonary embolism, as suggested by the ACCA position paper 1. Key aspects of pre-hospital care include:

• Continuous ECG and blood oxygen saturation monitoring
• Establishing intravenous access during transfer
• Considering point of care FoCUS echocardiography for evaluation of the severity of pulmonary embolism, if available and expertise is present 1
• Transfer to emergency departments or chest pain units for stable patients with suspicion of pulmonary embolism
• Transfer of patients with severe symptoms or hemodynamic instability to intensive care units in centers equipped for thrombectomy 1 Paramedics should exercise caution and prioritize rapid transport to definitive care, as anticoagulation therapy, thrombolytics, or surgical interventions are typically beyond their scope of practice. In cases of hemodynamic instability, echocardiography guided reperfusion therapy may be considered in the pre-hospital setting, if expertise is available 1. Overall, the goal of paramedic care for pulmonary embolism is to provide supportive care and expedite transport to a facility capable of definitive treatment, while minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Heparin Sodium Injection is indicated for: • Prophylaxis and treatment of venous thrombosis and pulmonary embolism;

The dosing recommendations in Table 1 are based on clinical experience be adjusted for the individual patient according to the results of suitable laboratory tests, the following dosage schedules may be used as guidelines:

Table 1: Recommended Adult Full-Dose Heparin Regimens for Therapeutic Anticoagulant Effect *Based on 68 kg patient METHOD OF ADMINISTRATION FREQUENCY RECOMMENDED DOSE Deep Subcutaneous (Intrafat) Injection Use a different site for each injection to prevent the development of hematoma Initial Dose 5,000 units by intravenous injection, followed by 10,000 to 20,000 units of a concentrated solution, subcutaneously Every 8 hours or 8,000 to 10,000 units of a concentrated solution Every 12 hours 15,000 to 20,000 units of a concentrated solution Intermittent Intravenous Injection Initial Dose 10,000 units, either undiluted or in 50 to 100 mL of 0.9% Sodium Chloride Injection, USP, as an intravenous injection

Treatment for pulmonary embolism under a paramedic scope of practice may include administration of heparin, as it is indicated for the treatment of pulmonary embolism.

• The initial dose for intermittent intravenous injection is 10,000 units.
• For deep subcutaneous (intrafat) injection, the initial dose is 5,000 units by intravenous injection, followed by 10,000 to 20,000 units of a concentrated solution subcutaneously. However, it is crucial to note that the administration of heparin should be guided by the patient's coagulation test results and adjusted accordingly, as specified in the dosage and administration section of the label 2.

From the Research

Treatment for Pulmonary Embolism under Paramedic Scope of Practice

• The primary goal of treatment for pulmonary embolism is to prevent death, reduce morbidity, and prevent thromboembolic pulmonary hypertension 3.
• Under a paramedic scope of practice, the initial treatment for pulmonary embolism typically involves administering oxygen and initiating anticoagulation therapy with heparin as soon as the diagnosis is suspected 4, 3.
• Paramedics may also consider the use of thrombolytic agents, such as alteplase, in patients with massive or submassive pulmonary embolism, although this decision should be made in consultation with medical direction and based on a careful risk-benefit analysis 5, 6.
• In cases where the patient is hypotensive, paramedics may use pressor agents such as norepinephrine, isoproterenol hydrochloride, or epinephrine to help manage blood pressure 4.
• Paramedics should also be aware of the potential for bleeding complications associated with anticoagulation and thrombolytic therapy and take steps to minimize this risk 5, 7.

Advanced Treatment Options

• In some cases, paramedics may need to consider advanced treatment options, such as surgical pulmonary embolectomy or catheter-directed thrombolysis, although these interventions are typically performed in a hospital setting 6.
• Paramedics should be familiar with the signs and symptoms of pulmonary embolism and be able to quickly identify patients who may require advanced treatment 4, 6.
• The use of extracorporeal life support and right ventricular assist devices may also be considered in severe cases of pulmonary embolism, although these interventions are typically reserved for patients with severe hemodynamic instability 6.

Importance of Multidisciplinary Care

• The treatment of pulmonary embolism requires a multidisciplinary approach, involving paramedics, emergency physicians, cardiologists, and other healthcare professionals 6.
• Paramedics should work closely with other members of the healthcare team to ensure that patients receive timely and effective treatment for pulmonary embolism 6.
• A management algorithm for the treatment of massive and submassive pulmonary embolism can help guide clinicians in individualizing treatment for patients and ensuring that they receive the best possible care 6.