IBCC Episode 53 - Submassive & Massive Pulmonary Embolism | The Internet Book of Critical Care Podcast

This podcast episode features a detailed discussion between Josh Farkas and Adam Thomas about the complexities of managing submassive and massive pulmonary embolisms (PE). They delve into risk stratification, emphasizing the importance of echocardiography and considering factors beyond clot burden. The conversation covers initial resuscitation strategies, including lab bundles and vital sign interpretation, highlighting the significance of bradycardia as a worrisome sign. They explore various treatment options, such as anticoagulation, thrombolysis, and advanced interventions like surgical embolectomy and ECMO, while also addressing unusual and confusing clinical scenarios related to PE management, including a critical review of the PECH score and the controversial PESI score. The hosts share their opinions on the optimal use of TPA, vasopressors, and pulmonary vasodilators, and stress the importance of avoiding unnecessary procedures like intubation and arterial lines.

Outlines

Part 1: Introduction, Diagnosis, and Risk Assessment

Part 2: Stratification Frameworks and Algorithms

Part 3: Physiology and Critical Care Management

Part 4: Thrombolysis and Anticoagulation Strategies

Part 5: Advanced Interventions and Surgical Options

Part 6: Special Scenarios, Emergencies, and Conclusion

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IBCC Episode 53 - Submassive & Massive Pulmonary Embolism

The Internet Book of Critical Care Podcast

Part 1: Introduction, Diagnosis, and Risk Assessment

00:05Introduction to Submassive and Massive Pulmonary Embolism

Introduction to Submassive and Massive Pulmonary Embolism

01:18Determining the Role of Pulmonary Embolism in Patient Instability

Determining the Role of Pulmonary Embolism in Patient Instability

04:54Vital Signs and Risk Stratification in Pulmonary Embolism

Vital Signs and Risk Stratification in Pulmonary Embolism

06:22Troponin and Lactate as Predictors of Mortality in Pulmonary Embolism

Troponin and Lactate as Predictors of Mortality in Pulmonary Embolism

07:52Right Ventricular Dilatation and Strain: EKG and CT Scan Signs

Right Ventricular Dilatation and Strain: EKG and CT Scan Signs

09:28Echocardiographic Signs and the Importance of Acute RV Dilation

Echocardiographic Signs and the Importance of Acute RV Dilation

Part 2: Stratification Frameworks and Algorithms

12:25Stratification Criteria and the Spectrum of PE Severity

Stratification Criteria and the Spectrum of PE Severity

14:11Additional Risk Factors and the Neutrophil-to-Lymphocyte Ratio

Additional Risk Factors and the Neutrophil-to-Lymphocyte Ratio

16:29The Walk Challenge and PE Risk Stratification Algorithm

The Walk Challenge and PE Risk Stratification Algorithm

17:36Algorithm for PE Risk Stratification

Algorithm for PE Risk Stratification

19:01Prognostic Features That Aren't Helpful: BNP, BOVA, and PESI Scores

Prognostic Features That Aren't Helpful: BNP, BOVA, and PESI Scores

21:20Risk Stratification and Thrombolysis Without a CT Scan

Risk Stratification and Thrombolysis Without a CT Scan

Part 3: Physiology and Critical Care Management

23:03The Death Spiral of Pulmonary Embolism: RV Dysfunction

The Death Spiral of Pulmonary Embolism: RV Dysfunction

24:40Procedures to Avoid and the Dangers of Intubation

Procedures to Avoid and the Dangers of Intubation

26:29Strategies for Intubation and Fluid Management

Strategies for Intubation and Fluid Management

28:39Inotropes, Vasopressors, and Pulmonary Vasodilators

Inotropes, Vasopressors, and Pulmonary Vasodilators

30:24Combining Pulmonary Vasodilators and the Role of Heparin

Combining Pulmonary Vasodilators and the Role of Heparin

Part 4: Thrombolysis and Anticoagulation Strategies

32:33Heparin and Thrombolysis: Timing and Evidence

Heparin and Thrombolysis: Timing and Evidence

34:51Thrombolysis: Reducing Cardiovascular Collapse and Safety

Thrombolysis: Reducing Cardiovascular Collapse and Safety

36:30Clot Resolution and Risk-Benefit Calculation

Clot Resolution and Risk-Benefit Calculation

38:14Contraindications to Thrombolysis

Contraindications to Thrombolysis

40:57The PECH Score and Thrombolysis Regimes

The PECH Score and Thrombolysis Regimes

42:23Quarter-Dose Thrombolysis and Evidence

Quarter-Dose Thrombolysis and Evidence

44:33Balancing Risk and Benefit in Lytic Therapy

Balancing Risk and Benefit in Lytic Therapy

47:02Catheter-Directed Thrombolysis and Heparin/TPA Coordination

Catheter-Directed Thrombolysis and Heparin/TPA Coordination

49:28Resuming Heparin After Thrombolysis and Tenecteplase

Resuming Heparin After Thrombolysis and Tenecteplase

Part 5: Advanced Interventions and Surgical Options

52:59Interventional Radiology: Catheter-Directed Thrombolysis

Interventional Radiology: Catheter-Directed Thrombolysis

55:17Percutaneous Mechanical Thrombectomy

Percutaneous Mechanical Thrombectomy

57:52Surgical Thrombectomy and ECMO

Surgical Thrombectomy and ECMO

1:00:22IVC Filters

IVC Filters

Part 6: Special Scenarios, Emergencies, and Conclusion

1:01:14Submassive or Massive PE in a Patient with Hemoptysis

Submassive or Massive PE in a Patient with Hemoptysis

1:03:55PE Patient with ST Elevation

PE Patient with ST Elevation

1:04:47Clot in Transit

Clot in Transit

1:07:24Clot in Transit Level 3 and PE with Refractory Hypoxemia

Clot in Transit Level 3 and PE with Refractory Hypoxemia

1:09:55Coding a PE Patient

Coding a PE Patient

1:12:20Summary, Pitfalls, and Conclusion

Summary, Pitfalls, and Conclusion