Key Principles
- Aggressive respiratory and cardiovascular supportive care
- Early anticoagulation with LMWH or UFH
- Thrombolysis if evidence of haemodynamic instability or cardiac arrest
Resuscitation & Supportive Care
- Airway and respiratory support:
- Apply 100% oxygen whilst assessing and titrate when patient stable 1
- Hypoxemia and respiratory failure may necessitate intubation: 1
- Should be avoided unless failing with non-invasive methods 1
- Positive pressure can lead to worsening hemodynamic status
- Circulatory support:
- Cautious IV fluid administration: 1
- May precipitate RV failure in strained right heart
- Unless clearly volume deplete limit fluid loading to 1L
- Early vasopressor requirement: 1
- Noradrenaline agent of choice
- Cautious use of inotropes 1– may worsen hypotension:
- Dobutamine agent of choice
- Cautious IV fluid administration: 1
- Prepare for possible cardiac arrest in the setting of haemodynamic instability: 1
- Ensure drugs and defibrillator readily available
- Provide prolonged CPR (if appropriate to patient’s overall condition) once thrombolysis given 1
Specific Management
- Anticoagulation:
- LMWH or fondaparinux as first line in clinically stable patients
- UFH in haemodynamically unstable patients
- Reperfusion Therapy:
- Thrombolysis:
- Indicated with high risk features (cardiac arrest, systolic <90 mmHg, drop in systolic by >40mmHg, obstructive shock)
- Alteplase first line:
- 10mg IV bolus loading
- 90mg IV infusion over 2-hours
- Accelerates lysis of clot, but associated with increased risk of major haemorrhage
- If refractory to treatment or thrombolysis contraindicated:
- Percutaneous catheter-directed treatment or thrombectomy
- Surgical thrombectomy
- Thrombolysis:
Referral & Deposition
- Multidisciplinary management with critical care, respiratory and interventional cardiology teams