Pulmonary Embolism (PE) | Acute Management | ABCDE

geekymedics.com/pulmonary-embolism-pe-acute-management-abcde-approach/

Dr Celestine Weegenaar August 21, 2018

A pulmonary embolism (PE) is life-threatening and must be recognised and

treated in a timely manner.

This guide gives an overview of the recognition and immediate management of

PE using the ABCDE approach. You can check out our overview of the ABCDE
approach here.

This guide has been created to assist students in preparing for emergency
simulation sessions as part of their training. It is not intended to be relied upon
for patient care.

Clinical features of a PE
A study in 2009 reported that in 1 in 4 patients with a PE, the first manifestation
will be sudden-unexpected death. ¹ PE is an important cause of out-of-hospital
and in-hospital arrest and as such is part of the 4 H’s and 4T’s of irreversible causes
of cardiac arrest.

The diagnosis of a PE cannot be made on examination alone. In fact, clinical

examination can be absolutely normal and unless you consider a PE as the cause
of your patient’s chest pain or shortness of breath (SOB) then you can easily miss it.

A PE should always be on your list as a cause of chest pain.

Risk factors
Risk factors for developing a DVT or PE include:

Recent surgery
Recent fractures
Recent immobility
Personal or family history of a clotting disorder or PE/DVT
 Obesity
Malignancy
Infection
Pregnancy
Certain medications such as the combined oral contraceptive pill or hormone
replacement therapy

When someone develops a PE and they have one of these risk factors it is referred
to as a ‘provoked PE’.

If there are no known underlying risk factors it is called a ‘unprovoked PE’.

Symptoms
Clinical features in order of frequency are:

Shortness of breath
Pleuritic chest pain:
The pain in PE is typically pleuritic (occurs during inspiration)
This is because with each breath, the pleura comes into contact with an
ischaemic area of lung
Cough
Haemoptysis – from infarcted lung tissue
Dizziness or syncope

Signs
Clinical signs include:

Tachypnoea: A respiratory rate of more than 20 breaths per minute

Tachycardia: A heart rate of more than 100 beats per minute
Hypotension:
This is a very worrying sign and suggests right ventricular strain
A raised JVP may also be noted in the context of right ventricular strain
Evidence of deep vein thrombosis (DVT) such as a red, swollen calf
A pleural rub or findings in keeping with a pleural effusion
Cyanosis is a late sign and indicates a significant drop in blood oxygen levels

Tips before you begin

Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management
is effective
Make use of the team around you to delegate tasks where appropriate
 All critically unwell patients should have continuous monitoring equipment
attached for accurate observations including:
Blood pressure
3-lead ECG
Oxygen saturations
Heart rate
Respiratory rate
Communicate how often you would like these observations to be relayed to
you
Call for help early using an appropriate SBARR handover structure (check
out the guide here)
You need to both request investigations and review results as they become
available
You don’t have to memorise everything off by heart, ask for guidelines and
algorithms that are relevant (i.e. PE treatment guidelines)
If you would like medications or fluids, these will need to be prescribed
Don’t forget to document everything you have found and done in the patient
notes!

Initial steps
You are likely to be called to see this patient either:

On the ward or
As a new presentation to ED with chest pain and/or shortness of breath

Inspection
Perform a quick general inspection of the patient to get a sense of how unwell
they are:

If the patient is unconscious, check for a pulse and check that the patient is
breathing.

If the patient is unconscious or unresponsive and not breathing start the basic
life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for
help! (see our BLS guide here)

Perform AVPU and assess their consciousness level

How do they look?
What is their breathing like?
Are there any clues from around the bedside? (look for drug charts,
medication, IV lines, monitoring equipment etc)

Interaction
 Introduce yourself to the patient
If the patient is able to answer questions, ask how they are feeling

Preparation

Ensure you have everything that is available to you

Patient notes
Drug charts including diabetes charts
Observations charts
If they have been an inpatient, have they been receiving
thromboprophylaxis?
Is the patient normally on warfarin/dabigatran/rivaroxaban/apixaban? (If so,
are they compliant with their medications?)

Airway

Assessment
Assess the patient’s ability to speak, listen to the patient’s breathing for added
sounds and inspect the mouth.

Intervention
If you think your patient has a compromised airway you need help! Put out a
crash call immediately as you require urgent anaesthetic input to secure the
airway. You can perform some simple airway manoeuvers in the meantime.

Maintaining the airway whilst awaiting senior support

1. Perform a head tilt, chin lift manoeuvre.

2. If noisy breathing persists, try a jaw thrust.

3.  If this is still not enough to open up the airway you can consider the use of an
airway adjunct:

If your patient is still semi-conscious then consider using a nasopharyngeal

(NP) airway.
If your patient is able to tolerate an oropharyngeal (OP, or Guedel) airway
then you can use one of these. However, this indicates that your patient is
seriously unwell as they no longer have a gag reflex.

Reassess after any intervention

If your patient starts to improve throughout your assessment, they may no longer
be able to tolerate the OP airway and you should remove it as soon as possible to
prevent gagging/aspiration.

Breathing

Assessment
Oxygen saturation: aim for 94-98%

Respiratory rate

Tachypnoea is the body’s response to hypoxia.

Impaired consciousness may lead to a reduced respiratory rate (bradypnoea).

Examination
Auscultate both lungs:

Reduced air entry bilaterally suggests significant airway compromise and the
need for critical care input.
Crackles or crepitations on auscultation may represent a pleural effusion due
to infarcted lung parenchyma.
Palpate and percuss to assess chest expansion and resonance/dullness.

Investigations

Arterial blood gas

An arterial blood gas may be useful to quantify the degree of hypoxia if your
patient has low oxygen saturations
ABG results in PE may show low PaO2 and normal/low PaCO2
A massive PE can lead to a metabolic acidosis

Chest x-ray

In most cases of PE, a chest x-ray will be completely normal. However, it is

a useful tool for ruling out other lung pathology (e.g. pneumonia).
CXR findings associated with PE include pleural effusion and/or an area of
atelectasis where a small area of lung tissue has collapsed.
A consolidation on the chest x-ray may represent an established area of
infarcted lung.

Well’s score
 At this stage, without any investigation results, you cannot be certain if you
are dealing with a PE or not.
The definitive diagnosis of PE can only be made with a CT pulmonary
angiogram (CTPA) or, less commonly, a VQ scan.
NICE guidance is to calculate clinical probability of DVT/PE using a 2-level
Wells score.²
A Well’s score assigns various clinical features a specific number of points
and you need to add up these points to determine the total Well’s score.

Clinical feature Points

Clinical signs/symptoms of DVT 3

PE is the most likely diagnosis 3

Tachycardia >100bpm 1.5

>3 days immobility or surgery in the last month 1.5

Previous DVT/PE 1.5

Haemoptysis 1

Malignancy 1

Clinical probability

PE likely >4 points

PE unlikely 4 or less points

If the Wells score is greater than 4 (PE is likely), a CTPA is indicated:

If there is going to be a delay in getting a CTPA you should start

anticoagulants in the meantime.
Refer to your local guidelines to see which anticoagulant is recommended
(this is often low molecular weight heparin or a novel oral anticoagulant
(NOAC).

If the Wells score is 4 or less and a PE is unlikely but still a differential to exclude,
a D-dimer test can then be used to rule out a PE (e.g. if D-dimer is negative, the
likelihood of a PE is very low).

As a result, those patients who are deemed low risk on the Wells score are
spared the risks of a CTPA if the D-dimer result is negative.
If the D-dimer result is raised (positive) then a CTPA or VQ scan will be
required to reach a definitive diagnosis of PE .
D-dimer can be raised for a number of different reasons other than the presence
of PE or DVT, so a raised D-dimer is not diagnostic for PE or DVT (it is used only to
help rule out the diagnosis). D-dimer can be raised due to infection, recent surgery
and malignancy.

VQ scans are typically used for patients for which CTPA is contraindicated (e.g.
renal impairment, contrast allergy, pregnancy).

Intervention

Oxygen

Administer oxygen as soon as possible:

High-flow oxygen (15 litres) through a non-rebreathe mask
If the patient is conscious, sit them upright
Maintain oxygen saturations between 94-98%

Assisted ventilations

If your patient is unconscious and their respiratory rate is inadequate (too

slow or irregular with big pauses), you can provide assisted ventilations
through a bag-valve-mask (BVM):
Ventilate at a rate of 12-15 breaths per minute (roughly one every 4
seconds)

PE treatment
If you can get a CTPA or VQ scan done quickly then you may be able to wait for the
definite diagnosis before implementing treatment. However, as there is usually at
least a small delay we often commence therapeutic doses of an anticoagulant
whilst awaiting investigation results.

Look at the guidelines available to you to see what anticoagulant agents are
recommended at your institution.
NICE guidance advises prescription of  low-molecular weight heparin,
fondaparinux or unfractionated heparin. ³
You should start an oral anticoagulant (NICE recommends warfarin) within
24 hours of diagnosis and continue it for at least 3 months.
Anticoagulant treatment may be continued for a longer period if the PE was
unprovoked (no known underlying cause).

A massive PE may require urgent treatment with an intravenous thrombolytic

agent. This is a consultant led decision and you should therefore seek urgent senior
review if you suspect massive PE.

Signs of massive PE occur secondary to right ventricular strain:

 Hypotension
Raised jugular venous pressure
Heart failure
Cardiac arrest

Reassess after any intervention.

Circulation

Assessment

Pulse

Your patient will most likely be tachycardic however some patients have a
normal heart rate despite PE

Blood pressure

Pain may lead to hypertension

Hypotension is a concerning sign and represents cardiac failure secondary to
right heart strain (massive PE)

Examination
Your patient may appear clammy/pale/grey
Capillary refill time may be normal or sluggish due to hypovolaemia

Investigations

Take blood samples

Try if possible to collect blood samples during cannulation

Troponin I or Troponin T: The cardiac enzymes are released from damaged
cardiac cells and are a key part of diagnosing myocardial infarction. PE can
cause a rise in troponin if there has been prolonged tachycardia and right
ventricular strain.
Full Blood Count: For a haemoglobin and platelet measurement. You can also
look for markers of infection.
CRP: For markers of infection/inflammation.
Urea and Electrolytes: To assess renal function (important if considering
CTPA)
Liver Function Tests and Clotting
Serum Glucose
Record an ECG

The most common ECG finding in PE is sinus tachycardia.

PE can cause any of the following ECG changes:

T wave inversion
New onset atrial fibrillation
Right bundle branch block
Right axis deviation
S1Q3T3 (this is a specific pattern that is seen rarely in PE):
S waves in lead I
Q waves in lead III
T wave inversion in lead III

Intervention

Secure intravenous access

The gold standard is to insert 2 large bore cannulas for acutely unwell
patients.

Administer IV fluids
Titrate your fluids to the patient’s level of haemodynamic instability
Typically NaCl 0.9% or Hartmann’s solution is used for fluid resuscitation

Reassess after any intervention.

Disability

Assessment

Blood glucose level

Check the patient’s blood glucose level, particularly if they are a known
diabetic

Assess pupils
What size are they?
Are they equal?
Are they reactive to light?

Assess level of consciousness- AVPU/GCS

 The above Airway, Breathing and Circulation problems can all alter the
patient’s neurological status because of decreased cerebral perfusion, causing
the patient to be confused or drowsy.
A formal record of your patient’s consciousness level will be really useful for
tracking progress and changes throughout treatment.

Reassess after any intervention.

Exposure

Assessment

Inspection
We routinely expose all unwell patients to make sure that we aren’t missing
anything.

Temperature
Patients with PE can develop a fever as part of the catecholamine response.

Urine output

Urine output will likely need monitoring if administering fluids, to ensure an

accurate fluid balance is recorded.

Reassess after any intervention.

Reassess ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter
them. This allows continual reassessment of the response to treatment and early
recognition of deterioration.

Next steps
Well done! You have successfully implemented the immediate treatment for your
patient. Your patient has been started on appropriate treatment and their
observations are improving. There are just a few more things to do…

Take a history
If possible, it is important to revisit history taking to clarify risk factors for PE and
other relevant medical information. If the patient is confused you might be able to
get a collateral history from staff or family members as appropriate. Check out the
history taking guides here.

Review
Patient notes
Observation charts
Fluid charts
Investigation findings
Additionally, make sure to check the medications you have just prescribed
and what the patient normally takes. This helps reduce prescribing errors
and allows you to consider any possible drug interactions.

Document
It is really important that you document your initial ABCDE findings, any
interventions you made and the response the patient had to those interventions.
Make sure to document salient points from the history.

Discuss
You need to discuss the patient with the medical team. If your patient requires a
higher level of care (HDU, ICU or CCU) then you need to speak to the appropriate
teams directly.

As a junior doctor it would be appropriate to give an SBARR handover outlining

your assessment, actions, and to discuss the following:

Does the patient need a referral to HDU/ICU?

Does the patient need further treatment?
Are there any further assessments, investigations or interventions required?
For example, an echocardiogram may be indicated to look for evidence
of heart strain.
Should they be referred for a review by a specialist doctor?
Should any changes be made to the management of their underlying
conditions?

References
1. Lucena, J., Rico, A., Vazquez, R., Marin, R., Martinez, C., Salguero, M. and Miguel,
L. (2009). Pulmonary embolism and sudden-unexpected death: prospective study
on 2477 forensic
2.https://pathways.nice.org.uk/pathways/venous-thromboembolism/diagnosing-
venous-thromboembolism-in-primary-secondary-and-tertiary-care#content=view-
node%3Anodes-pulmonary-embolism-likely

3.https://pathways.nice.org.uk/pathways/venous-thromboembolism/treating-
venous-thromboembolism#content=view-node%3Anodes-pharmacological-
interventions