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Home | Articles | Haematology and Thrombosis | Massive Pulmonary Embolism

Massive Pulmonary Embolism

Last updated 23rd December 2020

Definition

Massive PE has been defined as a PE associated with SBP <90mmHg or a drop in SBP ≥40mmHg from baseline for a period of >15min, which is not otherwise explained by hypovolaemia, sepsis or a new arrhythmia.
It is a catastrophy that often results in acute right ventricular failure and death. Frequently undiscovered until autopsy, fatal PE typically leads to death within 1-2 hours of the event.

Indications for Thrombolysis

The only widely accepted indication for thrombolysis is persistent hypotension (SBP <90mmHg) ie massive PE.
The latest NICE guideline on VTE (NG158, published 26 march 2020) states ‘Consider pharmacological systemic thrombolytic therapy for people with PE and haemodynamic instability’ and ‘Do not offer pharmacological systemic thrombolytic therapy to people with PE and haemodynamic stability with or without right ventricular dysfunction’

Initial Management

Move patient to HDU/ITU
Start unfractionnated heparin 5000u IV bolus followed by infusion 18u/kg/hr to maintain APTT 1.8-2.8.
Arrange urgent CTPA or cardiac echo if CTPA not possible
Rx oxygen, IV fluids and inotropic support as required.
If pregnant, inform on-call obstetric team immediately for consideration early delivery

How to Thrombolyse

Decisions regarding thrombolysis for PE should always be discussed with Consultant
Contraindications for thrombolysis are as for MI
Rx Alteplase (tPA) 10mg IV over 1-2 minutes followed by 90mg over 2 hours, max 1.5mg/kg if <65kg.
Discontinue anticoagulant therapy during infusion of tPA. When infusion complete, check APTT. Restart unfractionated Heparin without loading dose when APTT <2x ULN. If APTT > than this repeat every 4 hrs until <2x ULN then restart heparin.