PE Pathway. The charts are listed as follows:

Transcription

1 PE Pathway This document comprises 6 simple flow charts to assist clinicians in the investigation and treatment of suspected or confirmed Acute Pulmonary Emboli. The pathway has been put together using up to date evidence from American (ACP), European (ESC) and National (NICE, BTS and RCOG) Guideline. It has been reviewed locally by clinicians from Acute Medicine, Respiratory Medicine, Emergency Medicine, Haematology and Interventional Radiology. The charts are listed as follows: 1. Telephone Triage Management of Suspected Acute PE 2. Investigation of Suspected Acute PE in Hospital 3. Management of Confirmed Acute PE in Hospital 4. Thrombolytic therapy in PE 5. Investigation and Treatment of Suspected Acute PE in Pregnancy 6. Follow up of Acute PE Acute PE is a condition around which there is a lack of clinical confidence because it is common, presentation overlaps with many other conditions, it has a high mortality rate and is an area around which there have been clinical governance issue and medicolegal cases. Following some of the advice within this pathway should help clinicians standardise and rationalise the way that suspected acute PE is investigated and treated to follow best available evidence. As in most areas of medicine, however, there are few absolutes and clinical judgement needs to be applied.

2 1. Telephone Triage Management of Suspected Acute PE Clinical question Box 1 Simplified PESI Age >80 1 Score Clinical suspicion of PE Tachycardia (>110) 1 Systolic BP <100mmHg 1 SaO2 <90 1 Chronic lung or heart disease 1 Shocked? Hypoxic? Cancer (history or active) 1 No Yes spesi / PESI (PE severity Index) (See Box 1) ED Resus via 999 Low High Assessment of social and co-morbid clinical history Unable to Admit to AMRU Able to 2 Level Wells for PE (See Box 2) Reassess (See flowchart 2) 4 >4 1. GP to request D Dimer 2. Give LMWH Normal age-adjusted D dimer (Box 3) PE excluded (GP to reassess) D dimer elevated Give LMWH Admit to AMRU next day for imaging Clinical question Box 2 2 Level Wells for PE Clinical signs and symptoms of DVT 3 PE most likely diagnosis 3 Tachycardia (>100) 1.5 Immobilisation or surgery in previous 4 weeks Score 1.5 Past Hx DVT or PE 1.5 Haemoptysis 1 Active malignancy (palliative, on treatment or treated in past 6 months) 1

3 2. Investigation of Suspected Acute PE in Hospital Box 3 Age-adjusted D dimer In patient s who are <50 years old, levels above 500 should be being considered elevated. For patients over this age a cut off of Age x 10 can be used (eg in an 85yo, D dimer >850 should be considered elevated) NB. Patients MUST be Wells scored and those who have a Wells >4 should have imaging investigations (see flowchart) No Clinical suspicion of PE Shocked? (BP <90 systolic on 2 occasions 15mins apart) Yes 2 Level Wells for PE (See Box 2) Move to ED resus or Level 2/3 care 4 >4 1. Request D Dimer 2. Give LMWH (or DOAC) Normal age-adjusted D dimer (Box 3) D dimer elevated Give LMWH (or DOAC) Consider thrombolysis (See flowchart 4) PE excluded (Consider other diagnoses.?dc) spesi / PESI (See Box 1) Low High Assessment of social and co-morbid clinical history Unable to Admit to Acute Medicine Available same day PE confirmed - Ambulatory care (see flowchart 3). No PE - Consider other diagnoses?dc Able to Order imaging in ED/AMRU (See Box 4) Unable to image same day Ensure 1 st dose anticoagulation given. Safety-net. Bring back to AMRU at 9am for imaging Order imaging as IP (See Box 4) (See flowchart 3) Box 4 Imaging CTPA if first choice imaging for the majority of patients. VQ(SPECT) is first line for: 1. Contrast allergy 2. Renal impairment 3. Pregnant & no DVT 4. Female <40 with normal CXR* *Note in 4, a CTPA should be considered if the VQ is not available within 24 hours.

4 3. Management of Confirmed Acute PE in Hospital Box 4 Anticoagulation Most patients will be anticoagulated with LMWH acutely and a DOAC once diagnosis is confirmed. Warfarin remains an option depending on patient preference. For dosing in renal failure see appendix 1 in this document: %20Associated%20Specialties/Clinical%20Haematology/22 48.pdf On rare occasions where anticoagulation is contraindicated consider arranging insertion of a removable IVC filter until anticoagulation can be started safely. PE confirmed on imaging 1. Ensure anticoagulated (See Box 4) 2. Shocked? (BP <90 systolic on 2 occasions 15mins apart) No Yes spesi / PESI (See Box 1) Move to ED resus or Level 2/3 care Low High Assessment of social and co-morbid clinical history Consider thrombolysis (See flowchart 4) Able to Unable to Discharge on anticoagulation Arrange follow up as per flowchart 6 Admit to Acute Medicine 1. Troponin 2. Review CTPA for right heart strain 3. If diagnosed on VQ consider ECHO Risk Assess RV strain on imaging +/-ve Trop elevated +/-ve Intermediate-low (both ve or either +ve) Intermediate-high (both +ve) Box 5 Deterioration If a patient with intermediate-high risk PE develops any of the following during monitoring: 1. Hypotension (<90 systolic) 2. Significant increase in oxygen requirements 3. Further significant elevation of troponin They will need prompt senior review and clinical decision regarding suitability for rescue thrombolysis (see flowchart 4) If in ED or AMRU admit to Acute Med Likely 48 hour stay Reassess PESI at 48 hours. Step down if stable No deterioration Admit to MHDU / CCU Close monitoring for deterioration (See Box 5) Deterioration Consider rescue thrombolysis (See flowchart 4)

5 4. Thrombolytic therapy in PE Box 6 Indications for consideration of thrombolysis 1. Cardiac arrest with confirmed or suspected Acute PE 2. High clinical suspicion of PE with cardiovascular instability at presentation (Systolic BP <90mmHg repeated after 15min interval) 3. Confirmed PE within 14 days deemed to be high risk ie.systolic BP <90mmHg repeated after 15min interval 4. Confirmed intermediate-high risk PE (elevated troponin and right heart strain on imaging) who deteriorates despite anticoagulation (See Box 5) 5. Type A right atrial thrombus ( worm-like ) Note: if a patient has received low molecular weight heparin, this is not a contraindication for thrombolysis Protocol 1: Cardiac arrest 1. 50mg alteplase (as bolus in 50ml water for injections. 2. If not previously anticoagulated give 5000iu of unfractionated heparin 3. If ROSC then start UFH infusion and move to Level 2/3 area Box 7 Contra-indications of systemic thrombolysis Absolute: 1. Haemorrhagic stroke or stroke of unknown origin at any time 2. Ischaemic stroke within 6 months 3. Major trauma /surgery/head injury within 3 weeks 4. CNS damage or neoplasms 5. Gastrointestinal bleeding within 1 month 6. Aortic dissection Note: absolute CIs might become relative if lifethreatening PE Relative (Should be discussed) 1. TIA within 6 months 2. Oral anticoagulant therapy 3. Non-compressible vascular puncture 4. Pregnancy or within 1 week postpartum 5. Refractory hypertension (>180 systolic) 6. Advanced liver disease 7. Infective endocarditis 8. Active peptic ulcer disease 9. Disseminated malignancy 10. Known bleeding disorders Bleeding Risks Note that the risk of intracranial bleeding from all forms of thrombolysis is around 2% (increases with age and co-morbidities). The risk of non-intracranial bleeding is 6.3% Protocol 2: Non-cardiac arrest Please note that all guidelines recommend systemic thrombolysis as the first line treatment option unless there is a bleeding risk / contraindication Assess bleeding risk / contraindications (See box 7) No contraindications Systemic thrombolysis 1. 10mg alteplase given as bolus. 90 mg alteplase (or up to a maximum of 1.5mg/kg including bolus) as 2 hour infusion 2. Move patient to Level 2/3 area as soon as possible after bolus 3. If patient has not been anticoagulated, give 5000iu UFH immediately and start infusion. If they have already received LMWH then commence UFH when next dose due (12 or 24 hours) Assess response to systemic thrombolysis Improved Continuous monitoring for 48hrs Use UFH for the first 24 hrs after thrombolysis then switch to LMWH if stable and no bleeding Otherwise continue UFH CIs /Bleeding risk Consider Catheter-based clot disruption and suctionremoval (interventional radiology) treatment 1. Contact on-call IR consultant via switch to discuss 2. Ensure bed available in Level 2/3 area as soon as possible so that patient can be transferred directly post procedure Not Improved Deterioration

6 5. Investigation and Treatment of Suspected Acute PE in Pregnancy Clinical suspicion of PE Shocked? (BP <90 systolic on 2 occasions 15mins apart) No Yes Give LMWH at 1mg/kg bd (Use booking weight and if > 120mg bd call haematology) Inform obstetrics before 1 st dose if >36 weeks gestation ECG and CXR Move to ED resus or Level 2/3 care Assess for clinical signs DVT Doppler USS leg Present Negative Not present Review CXR Urgent involvement of Critical Care Team, Obstetric On-Call Consultant Normal Abnormal Give unfractionated heparin and organise confirmatory ECHO +/- CTPA in <1hour Positive VQ scan provided can be done within 24 hours, otherwise CTPA CTPA Positive Positive Negative Negative PE confirmed or high level of clinical suspicion in unstable patient PE confirmed 1. Request troponin 2. Review CTPA for right heart strain 3. If diagnosed on VQ/doppler consider ECHO Risk Assess RV strain on imaging +/-ve Trop elevated +/-ve PE excluded Review and consider discharge Consider thrombolysis (See Flowchart 4) Note - in peripartum patients, catheterdirected treatment may be necessary No right heart strain (Both ve and all obs stable) Senior clinical decision re discharge (spesi not applicable) Inform obstetrics Request VTEMDT on NoTIS to ensure follow up in haem/obs clinic on discharge Intermediate-low (both ve but concern re obs or either +ve) Admit to normal ward (ideally respiratory). Likely 48 hr stay Inform obstetrics Request VTEMDT on NoTIS to ensure follow up in haem/obs clinic on discharge Intermediate-high (both +ve) Deterioration Level 1/ARCU. Close monitoring for deterioration (See Box 5) Inform obstetrics Request VTEMDT on NoTIS to ensure follow up in haem/obs clinic on discharge

7 6. Follow up of Acute PE Planned discharge of patient with PE Nonpregnant Pregnant Review risk assessment and imaging Joint O&G / Haematology Clinic follow up To be arranged by. Low spesi at presentation and unilateral segmental / subsegmental PEs High spesi at presentation OR intermediate-low, intermediate-high or high risk PE OR bilateral / large central emboli Provoked Unprovoked Unprovoked Provoked Advise 3/12 anticoagulation If on DOAC then GP follow up, if on warfarin refer to anticoagulation clinic DC summary to advise LMWH cover for high risk situations eg surgery, POP immobilisation, long-haul flight (>4hrs) after 3/12 Rx completed Advise indefinite anticoagulation likely but this will be reviewed with patient at follow up For patients >40 please ensure that malignancy screening including Hx for red flags, full examination including breast in women, review of chest imaging, urine dip, FBC, U&E, LFT and Ca (+PSA in older men with symptoms) has been completed before DC. Patients should be told about assoc of VTE with malignancy and told not to ignore new symptoms in next 12 months Please request VTEMDT on NoTIS and appropriate follow up will be arranged Advise likely to be indefinite anticoagulation For patients >40 please ensure that malignancy screening including Hx for red flags, full examination including breast in women, review of chest imaging, urine dip, FBC, U&E, LFT and Ca (+PSA in older men with symptoms) has been completed before DC. Patients should be told about assoc of VTE with malignancy and told not to ignore new symptoms in next 12 months Refer all patients to the PE clinic by requesting VTEMDT on NoTIS. This will also arrange anticoagulation clinic follow up for those on warfarin Patients will be reviewed in 3/12 after ECHO to ensure no complications and to decide on duration of anticoagulation Advise 3/12 anticoagulation Refer all patients to the PE clinic by requesting VTEMDT on NoTIS. This will also arrange anticoagulation clinic follow up for those on warfarin Patients will be reviewed in 3/12 after ECHO to ensure no complications

8 Full Title of Guideline: Author (include and role): Division & Speciality: Version: 2 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Pulmonary Embolism Ivan Le Jeune Consultant Physician in Acute and Respiratory Medicine Medicine, Acute Medicine HTC, following consultation with clinicians at NUH. Trust wide November 2020 Patient with suspected or confirmed acute PE Minor updates ACP, ESC, NICE, BTS< RCOG Summary of evidence base this NICE QS29 guideline has been created from: AHA PE 2011 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.