Embolismo pulmonar masivo

PulmCrit: Pulmonary Intensivist's Blog

Eight pearls for the crashing patient with massive PE

July 9th, 2014

"Literature on massive PE focuses mostly on how to deal with the clot while less attention is spent on other aspects of management. This post will focus on such aspects, especially hemodynamic resuscitation of massive PE. There is nearly no clinical data, forcing us to extrapolate between limited data, hemodynamic theory, and experience. This post may be considered a working theory at best.

1. Understanding the hemodynamic death spiral of PE
2. Volume administration is seldom helpful, and potentially harmful.
3. Consider starting norepinephrine early to maintain an adequate blood pressure.
4. For treatment failure, consider inhaled nitric oxide.
5. Avoid intubation if possible.
6. Immediately determine contraindications to thrombolysis using a checklist.
7. For thrombolytic candidates, pursue thrombolysis early.
8. Plan for failure: Know how to code an arresting PE patient.

Take-home messages

• The only evidence-based intervention that seems to improve mortality in massive PE is thrombolysis. The primary goal of therapy should be administration of thrombolysis as soon as possible to patients without contraindication.
• Consider early stabilization of blood pressure using a norepinephrine infusion, administered peripherally if necessary.
• Volume administration may facilitate dilation of the right ventricle and hemodynamic deterioration. 
• Intubation is very hazardous and should be avoided if possible. Patients die from cardiovascular collapse, and intubation may worsen this.
• For a coding PE patient consider 50mg alteplase bolus as well as an infusion of epinephrine. Patients can do well despite requiring CPR and high dose vasopressor infusions."

http://www.pulmcrit.org/2014/07/eight-pearls-for-crashing-patient-with.html?m=1