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Should we Thrombolyse Patients with Submassive PE in

the Emergency Department?Dr Iain D M Beardsell MBChB FRCEM

Consultant in Emergency Medicine and Prehospital Emergency Medicine

University Hospital SouthamptonUK

What is A Pulmonary Embolism?

• Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has traveledfrom elsewhere in the body through the bloodstream (embolism).[1] Symptoms may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood.[2] Symptoms of a blood clot in the leg may also be present such as a red, warm, swollen, and painful leg.[2] Signs include low blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever.[3] Severe cases can lead to passing out, abnormally low blood pressure, and sudden death.[4]

• PE usually results from a blood clot in the leg that travels to the lung.[1] The risk of blood clots is increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, pregnancy, obesity, and after some types of surgery.[5] A small proportion of cases are due to the embolization of air, fat, or amniotic fluid.[6][7] Diagnosis is based on signs and symptoms in combination with test results. If the risk is low a blood test known as a D-dimer may rule out the condition. Otherwise a CT pulmonary angiography, lung ventilation/perfusion scan, or ultrasound of the legs may confirm the diagnosis.[8] Together deep vein thrombosis and PE are known as venous thromboembolism (VTE).[9]

• Efforts to prevent PE include beginning to move as soon as possible after surgery, lower leg exercises during periods of sitting, and the use of blood thinners after some types of surgery.[10] Treatment is typically with blood thinners such as heparin or warfarin.[11] Often these are recommended for six months or longer.[12] Severe cases may require thrombolysis using medication such as tissue plasminogen activator (tPA), or may require surgery such as a pulmonary thrombectomy. If blood thinners are not appropriate a vena cava filter may be used.[11]