Pulmonary Embolism Pathway Ambulatory Care Pathway Dr. A. Zafar, Dr. A. Rehman, Dr. T. Malik September, 2011. Patient Identification Label
Pulmonary Embolism Pathway Clinical History Comments Hospital Admission in last 90 days Surgery in last six months Smoker OCP/HRT Pregnant Refer to Flow Chart Malignancy Long Haul Travel (> 2hours) Previous thrombotic episode Family History of thrombosis WELLS SCORE Clinically Suspected DVT Alternative diagnosis is less likely than PE Pulse rate > 100 Immobilisation/surgery in previous 4 weeks History of DVT/PE Haemoptysis Malignancy (treatment for within 6 months, palliative) 3.0 3.0 1.5 1.5 1.5 1.0 1.0 CTPA Request Requirements: Mark request form For Ambulatory Pathway Wells Score D. Dimer Result Creatinine determination of creatinine clearance must not delay or modify administration of first does of LMWH Pink or Green Cannula (preferably at antecubital fossa) 2 P a g e
SUSPECTED SUSPECTED PE PE SOB SOB ± Pleuritic ± Pleuritic Chest Chest Pain, Pain, ± tachypnoea ± tachypnoea ± Haemoptysis ± Haemoptysis Clinical History including assessment for DVT Baseline Investigations: FBC, U & E, CRP, LFT, Coagulation Screen, ABG, CXR, ECG & D.Dimer Is patient physiologically stable? Oxygen Sats > 93%, Systolic BP > 100, Pulse < 100 and no confusion Marked hypotension, Systolic BP < 90, Profound Hypoxaemia Assess Probability According to Wells Score If Score > 4 PE Likely, start LMWH NEG for PE D. Dimer +ve CTPA If score < 4 Start LMWH POSITIVE for PE D. Dimer -ve Consider alternative diagnosis If imaging is not immediately available consider discharge on LMWH with next day recall for CTPA as ambulatory care Consider other diagnosis Physiologically stable Possible Massive PE Consultant to Consultant discussion Arrange Urgent CTPA & Echo Consider Thrombolysis Ambulatory care for confirmed PE START WARFARIN Admit for Inpatient Care All pregnant patients with suspected PE MUST be reviewed by the Obstetric Team 3 P a g e
Subcutaneous low molecular weight heparin (LMWH) Schedule (Using Tinzaparin Sodium in a strength of 20.000 Xa IU in 1 ml) Where patients are in renal failure (Creatinine Clearance <30 ml/min), it is essential to discuss anticoagulant management with a consultant haematologist. Determination of creatinine clearance must not delay or modify administration of first dose. Recommended treatment for patients with DVT in the absence of pregnancy (caution in acute Asthma) Pre-filled syringes of Tinzaparin can be used in pregnancy. Vials of Tinzaparin contain Benzyl alcohol which must be avoided in pregnancy. Once daily S/C injection based on body weight. Tick appropriate weight and dose used in box below Weight Kg Treatment with LMWH must continue for 6 days. Thereafter, it should not be stopped unless the INR is stable and within the therapeutic range of 2.0-3.0 or 3.0-4.0. Monitor platelets after 4 days of heparin treatment DATE: / / TICK Weight (Kg) Dose (ml) TICK Weight (Kg) Dose (ml) 130 1.15 80 0.70 125 1.10 75 0.65 120 1.05 70 0.60 115 1.00 65 0.55 110 0.95 60 0.55 105 0.90 55 0.50 100 0.90 50 0.45 95 0.85 45 0.40 90 0.80 40 0.35 85 0.75 4 P a g e
THROMBOPHILIA SCREENING TOOL Please tick below 1. DIAGNOSIS Was the VTE a sponatenous event? Was the VTE in an unusual site? E.g. axillary, mesenteric Is the patient < 45 years old? 2. PATIENT HISTORY Is there a previous history of spontaeneous PE or DVT? Is there a history of recurrent foetal loss (more than 3)? Is there a family history of thrombophillia? (Refer) Does the patient require Thrombophillia screening Date Signature 5 P a g e
Confirmed PE Ambulatory Clinic Work Up Consider Haematology referral for:- 1. Unprovoked PE 2. <45 years old 3. Strong family history of Thrombophillia 4. Recurrent PE s Consider Respiratory Referral for:- 1. Recurrent shortness of breath 2. Decompensated Corpulmonale For respiratory please order:- ECHO Lung Function Tests GP 6 P a g e
Criteria for suspected PE patients to be treated as outpatients: Are any of the following present? 1. Patient unstable Syncopal episode Haemodynamically unstable BP<100/60 Haemodynamically unstable P>100 Haemodynamically unstable RR>24 O2 sat<93% on air/requiring O2 Prior cardiorespiratory disease including PE Coexisting major DVT (high segment femoral and above) PE while on anticoagulation Chest pain not managed by oral analgesia 2. Severe renal dysfunction (egfr<30ml/min/11.73m 2 3. Active malignancy 4. Pregnant 5. Bleeding risk Coagulopathy Active bleeding Intracranial haemorrhage ever GI/GU bleed, trauma, surgery in past month Platelets<50 6. Allergy to warfarin/heparin or history HIT 7. Outpatient therapy not feasible in terms of - immobility compliance unlikely unable to obtain transport to and from hospital unable to access telephone at home unaware of adverse symptoms and how to obtain help If the answer to any of the above is yes then the patient should be admitted. Refs: Davies CWH, Wimperis J, Green ES, et al. Early discharge of patients with pulmonary embolism: a two-phase observational study, Eur Respir J 2007;30: 708-714 Hamad M, Chembo C, Ellidir E, et al. Safety of a pulmonary embolism ambulatory treatment (PEAT) program. Abstract at 2 nd conference of Society for Acute Medicine 2008. 7 P a g e
AMBULATORY CARE PATHWAY FOR CONFIRMED PULMONARY EMBOLISM Is the patient suitable for Ambulatory Care? Continue inpatient care Is patient/carer/partner able to administer LMWH DN service able to administer LMWH Home with LMWH supplies and Warfarin starter pack Go through checklist with patients and give copy MAU staff administer daily LMWH until INR therapeutic. Go through checklist with patients and give copy Refer to SWFT anticoagulant clinic electronically Print copy of referral and file in notes Consider outpatient or GP investigations of underlying causes (eg prostatic, urological or gynaecological tumours, other occult malignancy or infection, thrombophillia 8 P a g e
Pretest Probabilty for Malignancy Following Positive PE UR Number Name: Ultra sound scan Date: / / Calf Popliteal Femoral iliac Other Site Address: Preveious Thromboic History: Tel : GP: Known Malignancy Weight Loss > 7lbs in 6 months Recent Abdominal Pain Recent Alteration in Bowel Habit Haematurea / Malaena Bilateral DVT Unexplained PV Bleeding = Gynaecological Referral to any of the above questions refer patient for ABDOMINAL ULTRA SOUND SCAN Smoker or smoked within last 5 years Male > 60 years Male < 60 years with urinary problems Raised Plasma Viscosity = chest x-ray PSA PSA Biochemistry Screen Does patient require further screening for cancer History Taken By:- Date:- 9 P a g e