POTD: TPA in PE

POTD: TPA in PE

• Massive PE can lead to hemodynamic instability and death

• Smaller but clinically significant PEs can lead to pulmonary hypertension, RV dysfunction and subsequently poor quality of life (decreased exercise tolerance and even dyspnea at rest)

• TPA in PE is surrounded by controversy with various opinions on the matter

AHA:

• Massive: hemodynamic instability defined as SBP<90 (or 40 point drop from baseline) for >15 minutes=

• Thrombolysis indicated unless there are contraindications

• Sub-massive: hemodynamically stable but with signs of RV strain (elevated troponin/BNP, echo findings of RV dysfunction) = Thrombolysis may be considered (level IIb/C)

ACEP:

• Hemodynamically unstable patients: Thrombolysis indicated if benefits outweigh risks of bleeding

• Level B recommendation

• Hemodynamically stable patients: insufficient evidence to do thrombolysis

MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis):

If

• Symptomatic moderate defined as ≥2 signs/symptoms (7 total in inclusion criteria) in addition to CTPA involvement of >70% involvement of thrombus in ≥2 lobar, or left or right main pulmonary arteries

• Ventilation/perfusion scan showing mismatch in ≥2 lobes

• SBP<95 excluded

Then

• enoxaparin/heparin only vs enoxaparin/heparin + half dose tPA (10mg bolus then 40mg over 2 hours)

• primary end point: pulmonary HTN at 28 months

• rates in treatment group=16%, control group=57%

• combined end point: pulmonary HTN at 28 months + recurrent PE

• treatment group=16%, control group=63%

• no patients in either group bled

Conclusion:

• Studies suggest that half-dose thrombolysis is safe/effective in the treatment of moderate PE, with a significant immediate reduction in pulmonary artery pressure that was maintained at 28 months

• ”Thrombolytics have demonstrated faster improvements in RV function and pulmonary perfusion, but these benefits have not translated to improvements in mortality.”

• So the measured outcome is of questionable significance as opposed to actual measurements of quality-of-life

• Perhaps consider in your young patient in whom potential improvement in exercise tolerance in remaining lifetime may be more relevant than in older, immobile patients

Stay well,

TR Adam

POTD: Peripartum Cardiomyopathy

POTD: Peripartum Cardiomyopathy

Causes:

• Infectious (EBV, CMV, HSV)

• Genetics

• Pre-eclampsia

• Fetal cells present in the maternal system that elicit an inflammatory response

Clinical Findings (same as CHF findings):

• Tachycardia

• Decreased pulse oximetry (should be ≥ 97% at sea level).

• Blood pressure may be normal. (systolic >140 mm Hg and/or diastolic >90 mm Hghyperreflexia with clonus suggest preeclampsia).

• Elevated jugular venous pressure

• Third heart sound (turbulent ventricular filling secondary to poor wall relaxation from dilated ventricle)

• Loud pulmonic component of the second heart sound (increased right sided flow)

• Mitral or tricuspid regurgitation

• Pulmonary rales

• Peripheral edema

• Ascites

• Hepatomegaly

Management:

• CBC- to see if there is significant thrombocytopenia

• CMP- to see if there is any dysfunction in creatinine, LFTs, albumin

• Urine dipstick- to check if there is any proteinuria

• EKG

• Echocardiogram

• CXR

• Stress testing

• OBGYN, Cardiology consult in addition to reaching out to potential transplant hospitals

Treatment:

• Digoxin: first line in pregnancy

• Loop diuretics; Start with 10 mg of furosemide, as pregnant women have an increased glomerular filtration rate (GFR) that facilitates secretion of the drug into the loop of Henle.

• Hydralazine and nitrates: afterload and preload reduction

• B- Blockers (carvedilol or metoprolol): decrease all-cause mortality and hospitalization in those with systolic dysfunction.

• Heparin for EF<30% (high risk of venous and arterial thrombosis)

• LVAD

• May ultimately need heart transplant

• Delivery- Unless the mother is decompensating, you can manage her medically until delivery is possible. If the mother is not responding to medical therapy or if the fetus must be delivered for obstetric reasons, the best plan is to induce labor with the goal of a vaginal delivery. C-section can lead to a lot of dynamic fluid changes which can lead to maternal decompensation

Disposition: 

• ICU vs potential transfer to a center that offers tertiary care services for both the mother and the fetus.

Stay well,

TR Adam

EMS Protocol of the Week - Pediatric Asthma/Wheezing

Last week, we went over the REMAC protocol for asthma, but in a cliffhanger not seen sinceAvengers: Infinity War, we were all left wondering what NYC EMS does with asthmatic/wheezing kids. Well worry not, faithful readers, because this week we’re taking a look at Protocol 554 – Pediatric Asthma/Wheezing!

There are a bunch of pediatric-specific protocols (remember that for the NYC REMAC, pediatric means up to 15 years of age), each with certain differences from its adult counterpart. Some differences are subtle, some not, so it’s worthwhile to at least have some awareness that these peds protocols exist in case the OLMC phone rings for a kid.

Protocol 554 is a good place to start with pediatric protocols since it’s not hugely different from 507, which we discussed last week. Albuterol and ipratropium are still being utilized as Standing Order, although a half dose of ipratropium is instructed for kids less than 6 years old. Further, while the adult protocol permits for continuous albuterol to be used, the pediatric protocol only allows for 3 doses as Standing Order. For children older than one year in severe distress, medics will also give epinephrine as Standing Order at a weight based dose (up to 0.3mg IM, the adult dose). After this point, OLMC may be utilized to request additional albuterol nebs and repeat doses of epi.

At this point, the only other significant difference in management is that the pediatric protocol does not include steroids or magnesium as adjuncts to treatment, either as SO or MCO, so just be aware that these kids will likely not have received any of those meds by the time they reach the ED (as opposed to adult patients).

That’s pretty much it for pediatric wheezers. Similar to the adult protocol, this one will generally leave most kids (and their parents) feeling much better by the time you see them, but just be aware of what may or may not have been done for them before immediately sending them out the door.

We’ll revisit other pediatric-specific protocols in the future, so be sure to keep an eye out! In the meantime, here’s your weekly plug forwww.nycremsco.org and the protocols binder by the OLMC phone.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center