Pulmonary Embolism: Risk-Stratify & Treat

• Risk tiers drive therapy: massive PE (shock/PEA) → thrombolyse; submassive (RV strain + troponin) → anticoagulate ± intervention; low-risk patients → anticoagulate, sometimes as outpatients.
• Choose heparin when thrombolysis remains possible; DOACs (apixaban/rivaroxaban) are first-line in stable patients.
• Give alteplase 100 mg over 2 h (50 mg bolus in arrest); reserve IVC filters for contraindicated anticoagulation.
• Deteriorating submassive PE calls for catheter-directed therapy.

Workup of Suspected Acute Pulmonary Embolism (PE) in the Intensive

• Acute PE suspected → assess stability
• Hemodynamically unstable?
• Echocardiography, transthoracic or transesophageal
• RV dysfunction present (suggestive of PE)?
• Portable V/Q or Q scan, and/or proximal lower-extremity venous compression ultrasonography (CUS)
• Venous thromboembolism found? (high-probability V/Q, highly suggestive Q, or proximal lower-extremity DVT on CUS)
• Treat (→ Pathway 43.2)
• Look for alternative diagnoses
• No RV dysfunction (argues against PE) → look for alternative diagnoses
• Multidetector CT (if IV contrast contraindicated, consider V/Q scan, CUS, or MR angiography)
• CT positive for PE?
• Treat (→ Pathway 43.2)
• Look for alternative diagnoses — test further if PE still suspected or CT inadequate
• Attempt PE confirmation with additional testing; proximal lower-extremity DVT can serve as a PE surrogate in the right clinical setting

Treating Confirmed Acute PE in the ICU

• Acute PE — evaluate stability
• Hemodynamically unstable?
• Resuscitate (fluids, vasopressors) and anticoagulate; when anticoagulation is contraindicated, place an inferior vena cava filter (IVCF) — anticoagulate once the contraindication resolves
• Check RV dysfunction: echocardiography, multidetector CT · check RV injury: troponin, BNP
• RV dysfunction or injury?
• Dysfunction OR injury — keep treating; options to consider: catheter embolectomy · thrombolysis · surgical embolectomy if thrombolytics contraindicated
• Dysfunction AND injury — keep treating; STRONGLY consider: catheter embolectomy · thrombolysis · surgical embolectomy if thrombolytics contraindicated
• Neither dysfunction nor injury → continue Rx
• Anticoagulate, or inferior vena cava filter (IVCF) when anticoagulation contraindicated
• Check RV dysfunction: echocardiography, multidetector CT · check RV injury: troponin, BNP
• Any RV dysfunction/injury?
• Continue Rx; weigh cautiously: thrombolysis · catheter embolectomy
• Neither dysfunction nor injury → continue Rx
• Check contraindications before thrombolysis; temporary or permanent IVCF may be used