Patient may be having SOB for a few days prior to presenting in the ER, Sometimes, patient might also be misdiagnosed and getting treated for pneumonia by PCP. Patient may have cancer or be using oral contraceptive pills.
Routine Labs, EKG
CTA chest with PE protocol-Some may require Premedication for IV contrast dye allergy. If patient got CT chest with contrast and it was negative for any findings then it does not mean PE can be negative. We still have to do CT Angio with PE protocol little later if we suspect PE, to really rule out PE.
Premedication: Recommended Adult Premedication:
a. Prednisone – 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast media injection, plus Diphenhydramine (Benadryl®) – 50 mg intravenously, intramuscularly, or by mouth 1 hour before contrast medium.
b. Methylprednisolone (Medrol®) – 32 mg by mouth 12 hours and 2 hours before contrast media injection. An anti-histamine (as in option 1) can also be added to this regimen injection.
If Contrast can’t be given, order V/Q scan.
Telemetry admission as inpatient status if patient has hypoxia requiring several liters of oxygen or hemodynamic compromise like hypotension. If patient is not hypoxic or stable, admit as Observation status.
Supplemental oxygen if needed
Heparin drip for saddle embolus or severe clot burden in lungs or with severe kidney disease OR Lovenox SQ if kidney function allows and for low clot burden. Heparin is usually given as 80units/kg one time bolus plus 18units/kg/hr maintenance infusion to keep APTT in therapeutic level. Lovenox is usually given at 1mg/kg twice a day [every 12hrs].
The Heparin drip will have order set-different order set for different situations. Heparin drip for blood clots dosing is different than heparin drip dosing for heart issues. If you have question as to what you should choose, always ask the pharmacist. Order set has all the necessary orders that need to be ordered when giving heparin drip.
The nurses have protocol for heparin drip. They automatically follow that wrt dose titration based on APTT level.
Echo for severe symptoms like hypoxia, hemodynamic compromise etc to check if right heart strain is present or not.
Explain to the patient different blood thinners available like Warfarin, Eliquis, Xarelto etc. Once they choose which one they prefer start them.
If patient chooses Coumadin, it should be given with either heparin drip [Heparin bridging] or Lovenox SQ until INR is more than 2 which usually happens on third day after starting. Coumadin (Start at 5mg on first –>5mg again the second day–> further dosing depends on INR that needs to be done daily). Once INR is more than 2, heparin drip or Lovenox can be stopped.
You can also start Apixaban [preferred] for long term anticoagulation or Xarelto. Always, look up in Epocrates for medication info for correct dosing.
Ask case manager to find out if patient’s insurance would pay for these pills and if patient is ok with whatever ‘out of pocket pay’ that needs to be paid.
Order Hypercoagulable work up e.g. Anticardiolipin Antibody, Beta 2 Glycoprotein Antibody screen, Factor 5 Leiden Gene mutation, Factor 2 (Prothrombin) Gene screen, Lupus Anticoagulant Essay. Hematology/Oncology consultant can help with ordering these lab tests and follow up as outpatient as the results take a few days to come.
Consult Interventional Radiology if patient has Hemodynamic compromise.
If there is a contraindication to giving anticoagulation due to bleeding, consult Interventional Radiologist typically or vascular surgeon who can place IVC filter to prevent further clot deposition in lungs from legs or abdominal veins. Usually, they place retrievable IVC filters and you can get them out after a few months.
Check US of Lower Extremities to rule out DVT.
Make sure the patients are not short of breath when they walk in the hallway prior to discharging. Usually, insurance won’t pay for oxygen to take home if PE is the cause of hypoxia with ambulation. They only pay for chronic conditions like COPD, CHF etc. So, may have to wait until patient is no longer on oxygen prior to discharging.
If patient has DVT/PE provoked by surgery or immobility for any reason, anticoagulation is given for 3 months.
If patient gets a second episode of DVT or PE, anticoagulation is given lifelong.
SQ Lovenox is given for patients with DVT or PE due to cancer.