Management of a Patient with Suspected Pulmonary Embolism and Hypotension - Flowchart

Management of a Patient with Suspected Pulmonary Embolism and Hypotension - Flowchart

Management of a Patient with Suspected Pulmonary Embolism and Hypotension - Flowchart Pulmonary Embolism Pulmonary Embolism

«Flowchart»

Management of suspected PE in a patient with hypotension, shock, or cardiac arrest

Management of suspected PE in a patient with hypotension, shock, or cardiac arrest

Management of suspected PE in a patient with hypotension, shock, or cardiac arrest

Respiratory support

Respiratory support

Respiratory support Respiratory support

Cardiovascular support

Cardiovascular support

Cardiovascular support Cardiovascular support

Diagnosis

Diagnosis

Diagnosis Diagnosis

Bedside tests^*

Portable perfusion scan
Echocardiography
Venous ultrasonography

Bedside tests^*

Portable perfusion scan
Echocardiography
Venous ultrasonography

Bedside tests^*

^* *

Portable perfusion scan
Echocardiography
Venous ultrasonography

Portable perfusion scan
Echocardiography
Venous ultrasonography

Echocardiography

Echocardiography

Echocardiography

For SpO₂ <90%
Low-flow oxygen

For SpO₂ <90%
Low-flow oxygen

For SpO₂ <90%
Low-flow oxygen

O ₂

High-flow oxygen and positive airway pressure^†

High-flow oxygen and positive airway pressure^†

High-flow oxygen and positive airway pressure^†

^† †

Continue low-flow O₂

Continue low-flow O₂

Continue low-flow O₂

₂

PaO₂ >60 mm Hg, SpO₂ >90%

PaO₂ >60 mm Hg, SpO₂ >90%

PaO₂ >60 mm Hg, SpO₂ >90%

O ₂ O ₂

Yes

Yes

Yes

No

No

No

End

End

End

Vasoactive drugs

Vasoactive drugs

Vasoactive drugs

Intravenous fluid^§

Intravenous fluid^§

Intravenous fluid^§

^§ §

RV overdistended

RV overdistended

RV overdistended

Yes

Yes

Yes

No

No

No

Reperfusion intervention^¶

Reperfusion intervention^¶

Reperfusion intervention^¶

^¶ ¶

^*A bedside echocardiogram can support the diagnosis of acute pulmonary embolism (e.g., McConnell’s sign) or can provide another diagnosis (e.g., pericardial tamponade), and venous ultrasonography can show deep venous thrombosis.

^*A bedside echocardiogram can support the diagnosis of acute pulmonary embolism (e.g., McConnell’s sign) or can provide another diagnosis (e.g., pericardial tamponade), and venous ultrasonography can show deep venous thrombosis.

^*A bedside echocardiogram can support the diagnosis of acute pulmonary embolism (e.g., McConnell’s sign) or can provide another diagnosis (e.g., pericardial tamponade), and venous ultrasonography can show deep venous thrombosis.

^*

^¶Reperfusion interventions include thrombolysis, surgical embolectomy, and catheter-based treatment. The choice of reperfusion strategy depends on patient-related factors (e.g., bleeding risk and hemodynamic stability) and the institutional resources that can be mobilized (e.g., cardiovascular surgical team).

^¶Reperfusion interventions include thrombolysis, surgical embolectomy, and catheter-based treatment. The choice of reperfusion strategy depends on patient-related factors (e.g., bleeding risk and hemodynamic stability) and the institutional resources that can be mobilized (e.g., cardiovascular surgical team).

^¶Reperfusion interventions include thrombolysis, surgical embolectomy, and catheter-based treatment. The choice of reperfusion strategy depends on patient-related factors (e.g., bleeding risk and hemodynamic stability) and the institutional resources that can be mobilized (e.g., cardiovascular surgical team).

^¶

^†Suspect right-to-left shunting of venous blood when low-flow oxygen is insufficient. Provide high-flow oxygen. Assess the location of shunting (e.g., atelectasis and/or shunt through the foramen ovale). Provide positive airway pressure with mask ventilation and avoid intubation, if possible, for intrapulmonary shunt, and monitor and manage adverse effects of positive airway pressure on cardiac output.

^†Suspect right-to-left shunting of venous blood when low-flow oxygen is insufficient. Provide high-flow oxygen. Assess the location of shunting (e.g., atelectasis and/or shunt through the foramen ovale). Provide positive airway pressure with mask ventilation and avoid intubation, if possible, for intrapulmonary shunt, and monitor and manage adverse effects of positive airway pressure on cardiac output.

^†Suspect right-to-left shunting of venous blood when low-flow oxygen is insufficient. Provide high-flow oxygen. Assess the location of shunting (e.g., atelectasis and/or shunt through the foramen ovale). Provide positive airway pressure with mask ventilation and avoid intubation, if possible, for intrapulmonary shunt, and monitor and manage adverse effects of positive airway pressure on cardiac output.

^†

^§Intravenous fluids should be titrated carefully to avoid overdistention of the right ventricle (RV).

^§Intravenous fluids should be titrated carefully to avoid overdistention of the right ventricle (RV).

^§Intravenous fluids should be titrated carefully to avoid overdistention of the right ventricle (RV).

^§