Correct!
2. Initiate anticoagulation while performing review of any possible contraindications to tPA therapy.
The Antithrombotic Therapy and Prevention of Thrombosis Evidence Based Practice Guidelines recommend that patients with a high clinical suspicion of acute pulmonary embolism be treated with anticoagulants as compared to withholding treatment while waiting for diagnostic test results to become available (2). Those guidelines further recommend that in patients with hypotension (defined as a systolic blood pressure < 90) should also be treated with tPA if there are no contraindications. In addition, they recommend that patients at high risk for developing hypotension should be treated with tPA. However, a recent randomized, controlled trial did not demonstrate any benefit to treating patients with intermediate-risk PE with tPA and demonstrated that they are at increased risk for bleeding complications (3). The authors recommended not to use tPA unless the patient actually develops hemodynamic instability. If contraindications to tPA are present or there is a high risk of bleeding, then alternative therapies would need to be considered.
The ACCP Evidence Based Guidelines recommend catheter directed or surgical clot removal only when systemic tPA is contraindicated or has failed and the patient remains in shock. Additionally, local resources and expertise in either catheter directed or surgical clot removal needs to be available for those approaches to be considered.
Case Continued:
The patient suffered recurrent PEA cardiopulmonary arrests immediately following his return from the CT scanner. The CT images revealed large bilateral pulmonary emboli in the main pulmonary arteries. He experienced a return of spontaneous circulation following two subsequent PEA arrests with rapid and deep chest compression, hyperoxygenation and the administration of intravenous epinephrine. After he was resuscitated, he received IV tPA.
He was admitted to the Medical Intensive Care Unit (MICU) with metabolic acidosis due to diabetic ketoacidosis (DKA). This was successfully treated with intravenous fluids, insulin and electrolyte replacement. After the two hour tPA infusion was completed he was started on heparin. He was closely monitored in the MICU without further cardiopulmonary arrest or any hemodynamic instability. His alevolar:arterial gradient quickly improved and oxygen support was weaned. He was extubated the second hospital day and transferred out of the MICU on enoxaparin and warfarin.
Which of the following is true about the role of inferior vena cava (IVC) filters in the setting of massive PE? (Click on the correct answer to proceed to the next panel)