Acute hypoxic respiratory failure
Pulmonary Embolism

-- days of _ , S/G Onset, W/U/I Progression
-- SX: , sudden dyspnea or syncope, pleuritic chest pain, tachypnea, tachycardia, leg pain/swelling (DVT), fever
-- DENIES tearing chest/back pain, orthopnea/PND, fever/productive cough, unilateral pleuritic pain with absent breath sounds, RUQ/epigastric pain or leg swelling
-- Hx: AC use/adherence, prior VTE (provoking vs unprovoked),CKD,COPD/Asthma, Heart failure, CAD, AFib, Risk factors: recent surgery/immobilization, malignancy, estrogen/OCP use, pregnancy/postpartum, long travel, smoking, obesity, thrombophilia, Bleeding risk: prior GI/ICH bleed, active bleeding, thrombocytopenia, coagulopathy, liver disease, renal failure, recent surgery/trauma, concurrent antiplatelets/NSAIDs
-- Provoked: Immobilization (bedrest ≥3 days, ICU stay), Long travel (flight/car >4–8 hrs), Recent surgery, Trauma / fractures, OCPs, Pregnancy, Acute illness, Active cancer, lupus,
-- Unprovoked: No recent surgery, trauma, immobilization, or estrogen, No active cancer or clear illness
-- PE: tachycardia, tachypnea, hypoxia ± clear lungs, ± unilateral leg swelling, ± signs of RV strain (JVD, loud P2
-- initial W/U: CBC w/ diff, BMP (w/ GFR), troponin, BNP, PT/INR, PTT, fibrinogen, lactate. CXR , CTA chest PE protocol, bilateral LE venous US, limited echo (dialtion of RV, Paradoxical septal movement, TR), and EKG (RBBB,RVH)
-- MEDS: AC?
-- DDX: PE mimics: ACS, aortic dissection, ADHF, pericarditis/tamponade; pneumonia, pneumothorax, pleuritis, bronchitis; GERD, cholecystitis; costochondritis; anxiety/panic.

Plan (Pulmonary Embolism Add-On)

  • UFH (unstable/massive, possible tPA, thrombectomy, CrCl <30 or unpredictable course) (80/kg/per pharmacy) vs LMWH (Stable / floor / good kidneys) (1.5/kg/per pharmacy )

  • Apixaban 10mg BID for 7 days followed by 5mg BID (alternative -> for Rivaroxaban 15mg BID for 21 days followed by 20mg daily with dinner ) once stabilized with plan to treat for 3-6 months if provoked or indefinitely if unprovoked/recurrent PE. consider warfrin if Mechanical heart valve,Antiphospholipid Syndrome, or CrCl < 30

  • Fluid: can begin with 500cc bolus if e/o hypotension, careful not to overload RV

  • Pressor: if needed, start with norepinephrine

Advanced Therapy Options if needed

  • consult ICU/Cards for Systemic thrombolysis (tPA)immediately in unstable patients—no fixed time window

  • consult IR for Catheter-directed therapy (lytics OR Thrombectomy) if tPA contraindicated OR failed or no improvement after 24-48 hr initial therapy

  • VA-ECMO when Refractory shock / cardiac arrest or Bridge to thrombectomy

PE Risk Stratification

  1. Massive PE (High Risk)
    → PE with hemodynamic instability:

    • SBP < 90 mmHg ≥ 15 min OR need for pressors

    • Cardiac arrest / pulselessness

    • Severe bradycardia (< 40 bpm) with instability

  2. Submassive PE (Intermediate Risk)
    → PE with normal BP (SBP ≥ 90) BUT evidence of strain:

    • Right ventricular dysfunction (RVD) (echo/CT) and/or

    • Positive biomarkers (↑ troponin, ± BNP)

  3. Low-Risk PE
    → PE without:

    • Hypotension

    • RVD

    • Elevated cardiac biomarkers