Pulmonary embolism management in the emergency department: part 2

Management of high-risk pulmonary embolism in the emergency department: A narrative review

BACKGROUND

High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE.

OBJECTIVE

This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations.

DISCUSSION

High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions.

CONCLUSIONS

Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.

Acute Pulmonary Embolism Code and Rapid Response Teams are Necessary: A Review of Global and Mexico's Teams (MGH PERT)

Pulmonary embolism (PE) worldwide is an underdiagnosed disease; at the moment, there are no statistical data to make inferences regarding the thrombotic problem in Mexico. Although, in general, small emboli (subsegmental) are well tolerated in the pulmonary circulation, difficulties frequently occur for medium to large emboli that occlude more than 30% of the pulmonary circulation. In the United States, it is estimated that up to 100,000 PE-related deaths occur each year. A PE code consists of activating a group of specialists in PE for the consensual making of therapeutic decisions; it is beneficial for the clinical evolution of these patients and reduces their mortality; a PE response team (PERT) codes in reference hospitals to manage this disease. This report presents an updated summary of the PERT status globally and in Mexico, the explanation of why a PE code is necessary, and the effects of PERT teams in the detection (chronic thromboembolic pulmonary hypertension, chronic thromboembolic disease, and venous thromboembolism); therapeutic procedures (catheter-directed thrombolysis, systemic thrombolysis or surgical thrombectomy); selection of patients from low to high risk of PE; and future directions for PERT teams.

Predictive Model for Pulmonary Embolism in Pregnant and Postpartum Women: A 10-Year Retrospective Study

Background: Pulmonary embolism (PE) in pregnant and postpartum women is fatal, and risk assessment is crucial for effective and safe management, the aim of this retrospective study was to establish a nomogram for predicting the risk of PE in pregnant and postpartum women. Methods: Totally 343 subjects suspected of PE at the Obstetrics Department of Affiliated Dongyang Hospital of Wenzhou Medical University from January 2012 to December 2021 were retrospective analyzed in our study. Pregnant women suspected of PE and who underwent computed tomographic pulmonary angiography examination were included in the study. The least absolute shrinkage and selection operator regression technique was used to select the best prediction features, and multivariate logistic regression is used to build the prediction model. Bootstrap resampling 1000 times was used to validate the model visualized by nomogram. Evaluate the performance of the model from three aspects: identification, calibration and clinical utility. Results: Our predictive model indicated that chest tightness, anhelation, lactate, and D-dimer were associated with PE. The area under the receiver operating characteristic curve of the model was 0.836 (95% CI: [0.770-0.902]), indicating that our model had a good differential diagnostic performance. Good consistency between prediction and real observation was presented as the calibration curve. Decision curve analysis indicated that our model had a good net clinical benefit. Conclusions: We developed a novel numerical model for selecting risk factors for PE in pregnant and postpartum women. Our results may help obstetricians and gynaecologists to develop individualized treatment plans and PE prevention strategies.

Pulmonary embolism diagnosis: clinical assessment at the front door

This first of two practice reviews addresses pulmonary embolism (PE) diagnosis considering important aspects of PE clinical presentation and comparing evidence-based PE testing strategies. A companion paper addresses the management of PE. Symptoms and signs of PE are varied, and emergency physicians frequently use testing to 'rule out' the diagnosis in people with respiratory or cardiovascular symptoms. The emergency clinician must balance the benefit of reassuring negative PE testing with the risks of iatrogenic harms from over investigation and overdiagnosis.