Today we had a great discussion of the management of a massive vs sub-massive pulmonary embolism. We also discussed how management would change in the setting of large intra-atrial shunt.
Management Considerations for Acute PE:
-If escalating to intubation use a low PEEP as high PEEP decreases preload and patients with RV dysfunction are in a pre-load dependent state.
-If intubating use caution as induction medications can blunt the catecholominergic state.
-Give IVF, usually 500cc to 1L depending on situation, based on animal models using more fluids can be deleterious.
-If fluids do not resuscitate the patient then quickly move to vasopressors, NE is usually vasopressor of choice.
- Fibrinolysis vs Catheter directed fibrinolysis vs anticoagulation:
- Systemic Fibrinolysis is the preferred treatment for patients with massive PE if there are no contraindications to systemic fibrinolysis.
-Other possible treatments include catheter directed thrombolysis, surgical embolectomy, percutaneous embolectomy,
-Long Term Anticoagulation:
-Based on the 8/2016 CHEST guidelines, use of a NOAC is preferred over vitamin K antagonist for the treatment of PE.
The effect of an intra-cardiac shunt on acute pulmonary embolism physiology. The hypoxia seen in PE is thought to be due to right to left shunt and V/Q mismatch. When a patient has an acute onset increase in right heart pressure in the setting of a pre-existing intra-cardiac shunt the percentage of CO that moves through the shunt significantly increases (depending on the extent of RV dysfunction), this can be protective from a hemodynamic standpoint as it preserves LV CO, however it can significantly worsen hypoxia as seen in our patient.