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  #1  
Old 04-15-2014
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Help Help please with Pulmonary Embolism

I need some help clarifying the concepts regarding management of PE.

Here what I understood we do with a pt that present with signs of PE
1) evalation with well's criteria
2) if less then 4 --> PE is unlikely and we check D-dimer. If D dimer is < 500 PE is excluded. If d-dimer is >500 then we do CTA to clarify
3) if more than 4 PE is likely and we give HEPARIN ASAP (if no contraindication), and after we perform CTA. This will be followed by coumadin for 6 months

so far so good... now:

1st question. If the patient is unstable (low BP, hypoxia, tachycardia) we give thrombolytics... does it mean we give it if hypotension, hypoxia & tachycardia present together?? I guess yes, otherwise we would give it to pretty much everyone with PE, since the majority is tachycardic!

2nd question. What do we do if the patient is already taking heparin (but never had a clot before) and well's criteria are >4? Do we do CTA and we give warfarin if PE is confirmed? or we put a filter?

3rd question. when do we use the filter? my understanding is: when heparin and anticoagulants sre contraindicated, when pt has RECURRENT clots while on heparin or warfain, when the patient has FV disfunction (MTB just says instable patient)


please someone clarify!!!
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  #2  
Old 04-16-2014
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mmmm.... 89 people saw this post but nobody answered.
I can't believe nobody knows the management of PE
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  #3  
Old 04-16-2014
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Quote:
Originally Posted by vero View Post
I need some help clarifying the concepts regarding management of PE.

Here what I understood we do with a pt that present with signs of PE
1) evalation with well's criteria
2) if less then 4 --> PE is unlikely and we check D-dimer. If D dimer is < 500 PE is excluded. If d-dimer is >500 then we do CTA to clarify
3) if more than 4 PE is likely and we give HEPARIN ASAP (if no contraindication), and after we perform CTA. This will be followed by coumadin for 6 months

so far so good... now:

1st question. If the patient is unstable (low BP, hypoxia, tachycardia) we give thrombolytics... does it mean we give it if hypotension, hypoxia & tachycardia present together?? I guess yes, otherwise we would give it to pretty much everyone with PE, since the majority is tachycardic!

2nd question. What do we do if the patient is already taking heparin (but never had a clot before) and well's criteria are >4? Do we do CTA and we give warfarin if PE is confirmed? or we put a filter?

3rd question. when do we use the filter? my understanding is: when heparin and anticoagulants sre contraindicated, when pt has RECURRENT clots while on heparin or warfain, when the patient has FV disfunction (MTB just says instable patient)


please someone clarify!!!
In the 1st question, i think that the wells criteria is above 4. Remember that one of the most important points is that - Is the presentation likely to be a PE or not? +3 points.

So basically, If The presentation is MORE LIKELY a PE than anything else+ tachycardia , then thats pretty much wells +4 . If unstable, give heparin or thrombolytis , assuming there are no contraindications.


question 2- if the patient is already on heparin, and has a PE, then i dont see the point in also giving warfarin since he is already anticoagulated. The issue would be if the filter is warranted or not . I guess it would depend on the presentation, but most likely i would choose a support+CTA , if its the first TE

http://en.wikipedia.org/wiki/Inferio...ations_for_use

read this

question 3, i agree with these although i dont know what FV dysfunction is.
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vero (04-16-2014)
  #4  
Old 04-16-2014
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Quote:
Originally Posted by drivenby View Post
In the 1st question, i think that the wells criteria is above 4. Remember that one of the most important points is that - Is the presentation likely to be a PE or not? +3 points.

So basically, If The presentation is MORE LIKELY a PE than anything else+ tachycardia , then thats pretty much wells +4 . If unstable, give heparin or thrombolytis , assuming there are no contraindications.


question 2- if the patient is already on heparin, and has a PE, then i dont see the point in also giving warfarin since he is already anticoagulated. The issue would be if the filter is warranted or not . I guess it would depend on the presentation, but most likely i would choose a support+CTA , if its the first TE


http://en.wikipedia.org/wiki/Inferio...ations_for_use

read this

question 3, i agree with these although i dont know what FV dysfunction is.

Thank you!

q1. do you think if unstable then give heparin OR thrombolytic, but not both together?

q2. You would give warfarin anyway for 6 months. You always do in PE I think. But the question was more about what do do about the filter, because they say you put filter if there is RECURRENT clotting on heparin. I had a q with a pt on heparin that had a PE (never had before). What to do? I guess the answer would be CTA and.... support if PE confirmed? followed by warfarin?

q3. Sorry, I wanted to write RV disfunction.

thanks again
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  #5  
Old 05-05-2014
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Q1.The indications for giving thrombolytics in a case of PE are 1) Hypotension and 2) RV dysfunction. Tachycardia would not be an indication, as you rightly said, because it is present in most patients and the risks outweigh the benefits.
Q2. Why was the patient on heparin? was it a previous PE? If yes then put in a IVC filter, but continue warfarin, because the IVC filter itself is a foreign object and a nidus for formation of a thrombus! If for a unrelated indication, do not put IVC filter, do CTA, if PE confirmed, continue with heparin and add warfarin later.
Q3. RV dysfunction is an indication for thrombolysis not IVC filter. Rest of the indications are perfect.
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