Pulmonary Embolus (PE)

Question 1

Thrombolysis: Indications

Answer 1

1. Cardiac arrest (commonly PEA) 2dry to PE
2. Persistent hypoxia & respiratory distress unresponsive to maximal O2 therapy.
3. Large clot burden causing RV dysfunction
4. Shock (SBP<90, or 40mmHg drop from baseline w signs of shock)
5. Worsening symptoms despite anticoagulation

Question 2

Thrombolysis: Contraindications

Answer 2

1. Low risk PE (no RV strain)
2. Recent surgery last 14 days
3. ICH
4. GI/GU bleeding <21 days
5. On NOAC/LMWH/Warfarin INR>1.5
6. Platelet <100

Question 3

Thrombolysis : Complications

Answer 3

1. ICH/fatal hemorrhage 1.8%
2. Major Bleeding 9-13%
3. Minor bleeding 23%

Question 4

Thrombolysis: Dose

Answer 4

Alteplase 10mg IV bolus followed by IVI 90mg over 2 hrs
-> 50mg bolus in cardiac arrest (rpt 15mins if no ROSC)
-> continue CPR 90 mins post thrombolysis (ECMO if failing)

Question 5

ECG changes - PE

Answer 5

1. Sinus tachycardia
2. R axis deviation
3. T wave inversion
4. T wave flattening
5. S1 Q3 T3

Question 6

TTE in PE

Answer 6

• Thrombus in transit
• RV dysfunction - dilated, hypocontractile
• D sign - hypokinetic RV wall (McConnell Sign)
• Flaten or dyskinesis of interventricular septum

Question 7

CXR - PE

Answer 7

Hamptons Hump: Wedge shape pleural opacity in costophrenic angle
Westermark sign: prominent RA, abrupt cut off peripheral vessels

Question 8

Complications

Answer 8

Death, Cardiac arrest - PEA
Phlegmasia Cerulea Dolens - Complete occlusion of superficial & deep venous system, can progress to gangrene. Purple.
Phlegmasia Alba Dolens - Swelling leg, white, early compromised flow, painful.