Massive & Submassive Pulmonary Emboli

Massive Pulmonary Embolism

• Systolic BP <90mmHg
• Pulselessness
• Persistent Bradycardia
• Inotropic Support

Submassive Pulmonary Embolism

• Right Ventricular Dysfunction
• Right Ventricular Dilatation
• BNP > 90
• EKG Changes
• Elevated Troponin

Management

In patients with severe hypoxia and shortness of breath, consider NIPPV early, even before CT diagnosis. As the patient has increased Right sided failure and RV dilation, the patient will continue to have worsening RV ischemia and decreased RV contractility. As RV afterload increases you begin having worsening right sided failure and worsening cardiac output. In patients who require inotropes, consider norepi and dobutamine. 

• Early NIPPV and correction of hypoxia to prevent pulmonary vasoconstriction
• Decreased IV Crystaloid to prevent increased afterload and worsening RV function
• Norepi for patients requiring inotropic support. 

Systemic Thrombolytics

The use of systemic thrombolytics are supported by most protocols. Many RTCs have evaluated the use of thrombolytics, including half-dose and catheter-directed TPA. While mortality improves with thromolytic use in massive PEs, RTCs evaluating lytics in submassive PEs have been mixed. Catheter-directed intervention is a safe and effective treatment for both submassive and massive PEs.