Tx for PE + hypotension

[zzyzx]

I'm curious how you guys would treat a patient with a diagnosed PE (hypothetical, of course, for a pre-hospital case) and profound hypotension.

Would you give fluids? My understanding is that a fluid bolus can actually worsen the hypotension due to the R ventricle bulging into the L ventricle.

Would you give vasopressors or inotropes, and if so which ones?

Of course the definitive treatment is a thrombolytic, but I'm wondering if you guys would treat the hypotension prior to providing other treatments. There seems to be some controversy on this, so I'd like to hear your opinions.

 

[STXmedic]

An embolism large enough to cause significant backup into the right ventricle with associated hypotension? I think I'd read them their last rights....

 

[VFlutter]

An embolism large enough to cause significant backup into the right ventricle with associated hypotension? I think I'd read them their last rights....

+1

Inotropes are the only thing I can think of that *may* help but not to an extent that it would matter.

I am assuming by the scenario it would be a saddle embolus

 

[Veneficus]

I'm curious how you guys would treat a patient with a diagnosed PE (hypothetical, of course, for a pre-hospital case) and profound hypotension.

Would you give fluids? My understanding is that a fluid bolus can actually worsen the hypotension due to the R ventricle bulging into the L ventricle.

Would you give vasopressors or inotropes, and if so which ones?

Of course the definitive treatment is a thrombolytic, but I'm wondering if you guys would treat the hypotension prior to providing other treatments. There seems to be some controversy on this, so I'd like to hear your opinions.

Drive to hospital with very aggresive surgery department. Do not pass go. Do not collect $200.

 

[FLdoc2011]

IV fluids cautiously at first and then pressors. From what I've seen no good studies out on which pressor, use what you have I guess.

Ultimately get 'em to a surgeon, interventional radiologist, or at least ER that can push thrombolytics.

I've had a few saddle emboli that I've had the radiologist go in and tPA and/or do a catheter thrombectomy. Haven't had to go surgery route yet.

They can crash quickly though.

 

[Veneficus]

I've had a few saddle emboli that I've had the radiologist go in and tPA and/or do a catheter thrombectomy. Haven't had to go surgery route yet.

I think this is the future of surgery. The cases and days of open surgery are numbered.

 

[Aidey]

One of the very very few times I've ever had an ED doc tell me to go code 3 on a transfer was for a 30s male with a huge saddle PE.

The doc's last words to us as we walked out the door? "Oh, and try not to hit any bumps". :glare:

 

[NYMedic828]

I've never actually had a PE patient, as far as I know anyway.

What is the purpose of the pressors and fluid? Just to attempt to push the clot forward into less critical areas of bloodflow?

 

[mycrofft]

Drive to hospital with very aggresive surgery department. Do not pass go. Do not collect $200.

You mean, it can't be addressed and cured in an ambulance?:mellow:

 

[Akulahawk]

You mean, it can't be addressed and cured in an ambulance?:mellow:

Sure it can... but you have to pass "GO" and collect your $200 first. :blink:

 

[Veneficus]

What is the purpose of the pressors and fluid? Just to attempt to push the clot forward into less critical areas of bloodflow?

Desperation.

No more...No less...

 

[NYMedic828]

Desperation.

No more...No less...

So basically the only thing capable of making it better is a man with a scalpel and sterile room?

 

[VFlutter]

So basically the only thing capable of making it better is a man with a scalpel and sterile room?

Or thrombolytics

 

[NomadicMedic]

... And holy water. :/

 

[Veneficus]

Or thrombolytics

Such hope.

The effectiveness of systemic thrombolytics is under question in just about every acute pathology it is used in.

I would definately choose the surgical treatment if it were me.

 

[FLdoc2011]

And it's sometimes a tough call. The really bad ones I've seen that truly crashed go down fast and there was no time for anything. Once we pushed thrombolytics during the code since there was a known PE but we did t expect much at that point.

The ones that went to IR for thrombectomy or to have tPA infused via a PA catheter were relatively stable. They did have saddle PEs with evidence of heart strain either by ECHO or elevated troponins from stress on the RV but overall they weren't actively crashing or having refractory hypotension.

 

[Farmer2DO]

What is the purpose of the pressors and fluid? Just to attempt to push the clot forward into less critical areas of bloodflow?

To maintain a MAP compatible with life. To continue to perfuse the vital organs, while getting the patient to definitive therapy.

 

[NYMedic828]

To maintain a MAP compatible with life. To continue to perfuse the vital organs, while getting the patient to definitive therapy.

right but maintaining BP and perfusing vital organs isn't the problem. Lack of bloodflow to the lungs is the problem?

The heart is working fine I would think?

The organs are working fine. The organs need oxygen and can't get it because bloodflow to the lung is blocked no?

 

[VFlutter]

right but maintaining BP and perfusing vital organs isn't the problem. Lack of bloodflow to the lungs is the problem?

The heart is working fine I would think?

The organs are working fine. The organs need oxygen and can't get it because bloodflow to the lung is blocked no?

Why are they hypotensive? If there is a lack of blood flow to the lungs then there would be a lack of blood flow to the....?

 

[NYMedic828]

Why are they hypotensive? If there is a lack of blood flow to the lungs then there would be a lack of blood flow to the....?

Which further means the treatment serves 0 purpose...

You are still not moving blood... If you have a saddle embolism that reaches full occlusion, no blood moves. Game over no amount of pressor or fluid is going to fix it.

The patient is more than likely euvolemic. If the return of blood to the left atrium has been so diminished that the patient is hypotensive odds are its too late and even still only breaking up or removing the clot is a viable fix.

In my googling the only recommended intervention I can find is oxygen administration and prompt surgical intervention/thrombolytic administration.

Its like giving oxygen for a CVA. You can give all the O2 you want but it isn't going to reach anything you are just doing it because there is nothing else you can do...