NUH Emergency Department Guideline for Diagnosis & Treatment of PE (Massive and n-massive) in Adults only Contents Suspected Pulmonary Embolus in the ED Flow Chart Page 1 Administration of Thrombolysis for Massive PE Page 2 4 Adjusted guideline for suspected/confirmed PE in pregnancy Page 5 Wells Score for PE Page 6 Simplified PESI (Pulmonary Embolism Severity Index) Score Page 7 Initiation of treatment in (n-massive) PE Page 8 Discharge process for low PESI PE cases Page 9 Written by: Dr Ben Pope ED Consultant Dr Ivan Le Jeune Respiratory Consultant Dr Julian Warren ED SpR Sarah Warren Haematology Nurse Specialist Gemma Warren ED Pharmacist Charlotte Grimley - Haematology Consultant Gillian Swallow Haematology consultant Originallly written December 2014 Version 12 updated May 2017 Review December 2018
Suspected Pulmonary Embolus in the ED Flow Chart Is there a massive PE? (Suspect with the following): Systolic BP <90 Pulse <40 Cardiorespiratory arrest Calculate Wells Score + Score >4? Send D-Dimer + Is Result 500? Is EWS 3? Consider alternative diagnosis prior to discharge home Consider alternative diagnosis and admit to relevant specialty Calculate PESI score Score = 0 (Low Risk)? Request CTPA. Include phrase LOW PESI in request Is CTPA positive? Any Signs of Right Heart Strain? Send Troponin Raised? Needs discussion with Med Reg for High Level care ** Thrombolysis: Cardiac arrest dose: 50mg bolus Alteplase 5000iU heparin loading n-cardiac arrest: 10mg Alteplase bolus then 90mg over 2 hours* Enoxaparin** LOW PESI and medically fit? Discharge (Page 9) with referral to anti-coag clinic Request routine CTPA CTPA performed before bed ready? Admit to RAU** Admit to Medics** + except in third trimester & post-partum-see full guideline-page 5 * See full guideline for dosing < 65 Kg ** See guideline for enoxaparin prescription
Administration of Thrombolysis for Massive PE 1. Introduction This is a guideline to cover the administration of Thrombolysis medication for the management of Massive Pulmonary Embolus, as per the PE protocol. 2. Indication Massive PE is defined based on the following signs 1 : Systolic blood pressure <90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction Persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock). Cardiorespiratory arrest (imminent or actual) The decision to administer thrombolysis to a patient should be made by a SpR or Consultant. Patients should be consented for thrombolysis where possible (see below) 3. Contraindications te: Although contraindications are listed, it is ultimately the doctor s decision on whether to proceed ABSOLUTE: Haemorrhagic stroke or stroke of unknown origin at any time. Ischaemic stroke in preceding 6 months. CNS trauma or neoplasm. Recent major trauma/surgery/head injury (3 weeks). GI bleeding within last 3 months. Known bleeding disorder. Aortic dissection. n-compressible puncture (e.g. liver biopsy, lumbar puncture). RELATIVE: TIA in preceding 6 months. Oral anticoagulant therapy. Pregnancy or within 1 week post-partum. Refractory hypertension (Sys > 180 mmhg or Dias > 110 mmhg). Advanced liver disease. Active peptic ulcer disease. Refractory Resuscitation. 4. Treatment Alteplase (rt-pa, tissue-type plasminogen activator) (Actilyse ) is the thrombolysis agent of choice in PE. For cardiac arrest: 1. Alteplase Administer one 50mg vial as a bolus (in 50ml Water for Injection) 2. Heparin 1 Jaff M. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association.2011. http://circ.ahajournals.org/content/123/16/1788.full.pdf
Administer 5000 units IV After the 5000 unit bolus heparin therapy should be resumed when aptt values are less than twice the upper limit of normal. The infusion should be adjusted to maintain aptt between 50-70 seconds (1.5 to 2.5 fold of the reference value). For non-cardiac arrest: 1. Alteplase 2x 50mg vials required. Reconstitute with 50ml Water for Injection Administer 10mg (5ml) by slow IV injection over 1-2 minutes. Follow up with administration of the remaining 90mg (45ml) via syringe driver over 2 hours (22.5ml/hr) o For patients who weight <65Kg give max of 1.5mg/Kg total dose, 10% as a bolus and 90% via syringe driver over 2 hours o For example, a patient who weighs 50Kg would need: 50 x 1.5 = 75mg total dose. 7.5mg bolus followed by 67.5mg over 2 hours (If there is no syringe driver available, you can dilute further into a bag of 0.9% saline (minimum concentration 0.2mg/ml mixed solution) and administer via a volumetric pump) Compatibilities: 0.9% Saline DO NOT mix with: Glucose 5%, Heparin, GTN or any other medicines. Should be administered through a separate giving set and cannula. 2. Low Molecular Weight Heparin Enoxaparin (Clexane) is our LMWH of choice at NUH. Dose: o For n-pregnant patients: 1.5mg/Kg by Sub Cutaneous injection. Once Daily until adequate oral anticoagulation is established. o For Pregnant patients: 1mg/Kg by Sub Cutaneous injection. Twice Daily until adequate oral anticoagulation is established. (Max dose 100mg BD)-prescribe at early pregnancy weight 5. Cautions/Side Effects of Alteplase Side Effect Sudden Hypotension Severe Bleeding Hypertension Action Check patient if symptomatic, lay patient flat and monitor BP at frequent intervals. If hypotension persists, seek senior medical advice. Give fluid resuscitation as required. Inform senior medical staff. If heparin administered within 4 hours of onset of bleeding, protamine may be considered cautiously and the APTT ratio rechecked If systolic BP >180mmHg or diastolic >105mmHg, consider buccal GTN 2-6mg or administering an IV bolus dose of metoprolol 2.5mg (provided there is no evidence of heart block, left ventricular failure, bradycardia or asthma). If ineffective, an IV infusion of glyceryl trinitrate may be commenced.
Allergic reaction Arrhythmias Heart block/ Bradycardia Ventricular Tachycardia Give 0.5ml (500micrograms) Adrenaline (1mg in 1ml) 1:1000 IM, Consider hydrocortisone 200mg and chlorpheniramine 10mg IV. If reaction persists or is severe, consult senior medical staff. Check BP if patient is symptomatic and/or hypotensive (<90mmHg systolic) administer IV atropine 500micrograms and repeat up to a maximum of 1mg until heart rate >60bpm. If ineffective, seek medical advice Follow UK Resuscitation Council guidelines 6. Consent for thrombolysis Written consent for thrombolysis is not required, however, verbal consent must be obtained where possible, prior to the administration of any thrombolytic drugs, and documented in the case notes. As well as stressing the benefits of thrombolytic drugs, patients must be informed of the side effects and potential risks incurred by administering them i.e. increased risk of bleeding including: o Cerebral bleed incidence more than 1 in 1000, but less than 1 in 100 o Gastrointestinal bleed - incidence of more than 1 in 100, but less than 1 in 10 o Bleeding from intravascular lines, attempted venepuncture sites (common
Adjusted guideline for suspected/confirmed PE in pregnancy Use NUH guidance attached: http://nuhnet/nuh_documents/guidelines/family%20health/obstetrics%20and%20maternity/1096. pdf Page 19 of the above guideline serves as a summary slide For all pregnant patients and patients 6 weeks Post-partum: o Do not perform D-dimer o Request bilateral USS of lower legs o ADMIT to Obstetric ward, ensure intra-uterine pregnancy o Elevate leg, put on graduated elastic stockings o Inform Obstetrician booked under and maternal medicine team o Start ENOXAPARIN ( Clexane ) unless contraindication (eg labour imminent >38 weeks) If bilateral USS negative, proceed to V/Q scan rather than CTPA If USS positive, treat as PE
Well s Score for PE 2,3 Available online at: http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ Otherwise: Clinical Signs/Symptoms of DVT +3 PE is primary diagnosis, or equally likely +3 Tachycardia (Pulse > 100) +1.5 Immobilisation for 3 or more days or surgery within last 4 weeks +1.5 Previous history of PE or DVT +1.5 Haemoptysis +1 Active malignancy (Treated within last 6 months, or palliative) +1 If Total score > 4, calculate a PESI score. 2 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. 3 Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004 v;44(5):503-10.
PESI (Pulmonary Embolism Severity Index) Score 4 Available online at: http://www.mdcalc.com/simplified-pesi-pulmonary-embolism-severity-index/ Otherwise: Age >80 +1 History of Cancer +1 History of Chronic cardiopulmonary Disease +1 Heart rate 110 +1 Systolic BP < 100mmHg +1 O 2 Saturations < 90% +1 Score: 0 Low Risk 1.1% 30 day mortality 1 and above High risk 8.9% 30 day mortality 4 Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6
Initiation of Treatment in (non-massive) PE 1. Introduction This is a guideline for initiation of treatment in PE, not requiring thrombolysis 2. Indication Suspected PE without any of the following: Systolic BP < 90 Cardiorespiratory arrest (imminent or actual) Treatment should start as soon as possible after suspected diagnosis of PE, you should not wait for confirmation of diagnosis unless the risk of harm with treatment outweighs the risk of delaying treatment. 3. Treatment The British Thoracic Society recommends 5 : Low Molecular Weight Heparin (LMWH) is the drug of choice unless there is the likelihood that rapid reversal of anticoagulation may be needed Where rapid reversal of anticoagulation may be required, patients should be loaded with unfractionated heparin and continued with an infusion (as with massive PE guideline above). Low Molecular Weight Heparin Enoxaparin (Clexane) is our LMWH of choice at NUH. Dose: For n-pregnant patients: 1.5mg/Kg by Sub Cutaneous injection. Once Daily until adequate oral anticoagulation is established. For Pregnant patients: 1mg/Kg by Sub Cutaneous injection. Twice Daily until adequate oral anticoagulation is established. (max dose 100mg BD) 2 -dose at early pregnancy weight Unfractionated Heparin Loading Dose: 5000 units or 75 units/kg Continuing Infusion:18 units/kg/hr adjusted according to APTT 4. Contraindications te: Although contraindications are listed, it is ultimately the doctor s decision on whether to proceed Haemophilia and other haemorrhagic disorders Thrombocytopenia Recent cerebral haemorrhage Severe hypertension Peptic ulcer Recent major trauma or surgery 5 British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470 484 2NUH Guideline for the management of acute thromboembolism in pregnancy and the puerperium, April 2012
Discharge Process Patients with a Low PESI score, who are able to take oral anticoagulants and who are medically fit and not needing oxygen with an EWS <3 can be safely discharged for follow up in haematology anticoagulation clinic. These patients do not need follow up by the respiratory team. If your patient does not meet these criteria, discuss with a senior doctor in ED for likely referral to the medical team. Discharge Process: Review results of all blood tests including FBC, UE, LFT and Coag prior to referral Check there are no contraindications to prescribing Rivaroxaban-use the following link: http://www.nottsapc.nhs.uk/attachments/article/3/doacs_for_vte.pdf o If there are contraindications admit the patient to the medical team short stay area. Do not discharge. o If there are no contraindications, write a TTO for Rivaroxaban 15mg BD for 21 days and complete referral to anticoagulation clinic using code ACOAG in tis