A 58 year old man is brought in by ambulance moribund with barely palpable pulse and a sinus tachycardia.


(c) A large pulmonary embolus is confirmed.  What management will you institute? 

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College Answer

{c) At last a diagnosis. Management at this stage would depend on his clinical state  and include supportive measures (02, inotropes, ulcer prophylaxis) and specific (heparin, IVC filter). Dobutamine (lesser forms of haemodynamic disturbance) and noradrenaline (severe RV failure) are the only inotropic agents supported by evidence in this setting.-Adrenaline·may be the only ··

agent immediately available on the arrest trolley though.

NB. Excessive fluid may distend the RV and worsen the situation.

(i)       If resuscitated  adequately and haemodynamically  stable, IV  heparin would be the mainstay. Venous .duplex scans may help to gauge further  thrombus load. The history of DU and a large mobile DVT may be an indication for insertion of a caval filter but lysis appears contraindicated if the history is confirmed.

(ii)      If the patient is haemodynamically  unstable and on  large doses of vasopressor (preferably noradrenaline at this stage).embolectomy on bypass is indicated. Fibrinolysis is contraindicated by recent surgery and DU.

Discussion

A question like this would benefit from a systematic answer.

  • Attention to ABCs, with correction of immediately life threatening complications
  • Airway
    • intubation may be required to apply a controlled FiO2
  • Breathing
    • Increase FiO2 to correct hypoxia
  • Circulation
    • Fluid boluses to carefully increase right heart preload
    • pulmonary vasodilator and inotrope eg. milrinone, to increase forward flow though the pulmonary circulation
    • inhaled pulmonary vasodilators, eg nitric oxide or prostacycline
  • Anticoagulation/thrombolysis
    • thrombolysis likely to be absolutely contraindicated given the history of recent surgery
    • anticoagulation may be relatively contraindicated if there are evolving intracranial haemorrhagic events
  • Rescue therapy
    • Embolectomy
    • Clot lysis / clot retrieval by interventional radiology
    • VA ECMO if anticoagulation not contraindicated and other measures fail or are not available
  • Preventative therapy
    • long term anticoagulation
    • vena cava filter