What is the management for a patient who suffered a pulmonary embolism in the ward?

Management of Pulmonary Embolism in the Ward

For a patient who has suffered a pulmonary embolism in the ward, immediate risk stratification followed by appropriate anticoagulation therapy is essential, with thrombolysis reserved for hemodynamically unstable patients with high-risk PE. 1

Immediate Assessment and Risk Stratification

1. Hemodynamic Assessment:

   • Classify PE severity:
     • High-risk (massive): Hemodynamic instability, shock or hypotension
     • Intermediate-risk (submassive): Hemodynamically stable with right ventricular dysfunction
     • Low-risk: Hemodynamically stable without right ventricular dysfunction 1

2. Initial Monitoring:

   • Continuous ECG monitoring
   • Blood oxygen saturation monitoring
   • Establish intravenous access 2
   • Consider point-of-care focused cardiac ultrasound (FoCUS) to evaluate right ventricular function 2

Treatment Based on Risk Stratification

High-Risk (Massive) PE with Hemodynamic Instability

1. Immediate Thrombolysis:

   • Alteplase 100 mg over 2 hours, or 0.6 mg/kg over 15 minutes (maximum 50 mg) 1
   • For patients >75 years old, consider half-dose regimen 2

2. Alternative Options (if thrombolysis is contraindicated or fails):

   • Surgical embolectomy
   • Percutaneous catheter-directed interventions
   • ECMO for refractory circulatory collapse 1

3. Hemodynamic Support:

   • Avoid fluid challenges as they may worsen right ventricular overload
   • Consider vasopressors: norepinephrine, isoproterenol, or epinephrine 3
   • Transfer to intensive care unit 2

Intermediate and Low-Risk PE (Hemodynamically Stable)

1. Anticoagulation Therapy:

   • Start without delay in patients with confirmed PE 1

2. Initial Anticoagulation Options:

   • Low molecular weight heparin (LMWH) or fondaparinux preferred over unfractionated heparin 1

3. Transition to Oral Anticoagulation:

   • Non-vitamin K antagonist oral anticoagulants (NOACs) preferred over vitamin K antagonists 1
   • For treatment of PE, apixaban dosing: 10 mg twice daily for 7 days, followed by 5 mg twice daily 4

Special Considerations

1. Contraindications to Anticoagulation:

   • If anticoagulation is contraindicated (e.g., intracranial hemorrhage), consider inferior vena cava filter placement 5
   • Resume anticoagulation as soon as contraindication resolves

2. Duration of Anticoagulation:

   • Minimum 3 months for all patients 1
   • For PE associated with temporary risk factors: discontinue after 3-6 months 6
   • For unprovoked PE: consider extended/indefinite treatment based on bleeding risk 1
   • For reduction in risk of recurrent PE after initial therapy: apixaban 2.5 mg twice daily 4

3. Multidisciplinary Approach:

   • Consider involving a PE response team (PERT) for complex cases, including specialists from critical care, hematology, and interventional radiology 1

Follow-Up and Long-Term Management

1. Clinical Evaluation:

   • Schedule follow-up at 3-6 months after acute PE 1
   • Assess for:
     • Persistent symptoms
     • Signs of recurrence
     • Bleeding complications
     • Need for extended anticoagulation

2. Screening for Complications:

   • Evaluate for chronic thromboembolic pulmonary hypertension (CTEPH) if persistent symptoms are present 1

Common Pitfalls to Avoid

1. Premature Discontinuation of Anticoagulation:

   • Increases risk of thrombotic events
   • If discontinuation is necessary (other than for bleeding), consider bridging with another anticoagulant 4

2. Delayed Recognition of High-Risk Features:

   • Failure to identify hemodynamic compromise requiring thrombolysis
   • Missing right ventricular dysfunction on imaging

3. Inappropriate Fluid Administration:

   • Excessive fluid can worsen right ventricular function in PE
   • Judicious fluid management is critical

4. Inadequate Monitoring:

   • Failure to monitor for bleeding complications during anticoagulation
   • Lack of follow-up for chronic complications like CTEPH

By following this structured approach to PE management based on risk stratification, patients can receive appropriate treatment that reduces mortality and morbidity while minimizing complications.