“Coding A PE [Pulmonary Embolus] Patient” From Dr. Farkas’ Book Of Internet Critical Care “Submassive and Massive PE” &

This post contains the excerpt, Coding A PE Patient, from Dr. Josh FarkasIBCC Chapter & Cast – Submassive & Massive PE, September 5, 2019. [Link To IBCC Podcast] [Link To IBCC Chapter].

Note to myself: You can’t review the complete podcast and chapter too often. But this post is just a reminder of how to approach cardiac arrest in a pulmonary embolus patient.

coding a PE patient

Patients can survive and do well despite coding from a PE (with survival >50%). A few useful components to this:

  • Thrombolysis:
    • Regardless of the patient’s contraindications, they should receive thrombolysis (unless immediate ECMO is an option).
    • The code dose of alteplase which is best evidence-supported seems to be a 50 mg IV bolus (27422214).  However, if 100 mg is available, administering this entire dose may also be reasonable.
    • Tenecteplase may be faster to mix up, so that is another option.
  • Epinephrine:  If the patient regains a pulse after an epinephrine bolus, strongly consider immediately starting a high-dose epinephrine infusion (e.g. 20 mcg/min, then titrate based on blood pressure).   These patients often seem to re-arrest after the epinephrine bolus wears off.
  • Limit airway pressures, as discussed above (avoid over-aggressive bagging).
  • Inhaled pulmonary vasodilator – Consider administration of any pulmonary vasodilator available via the endotracheal tube (e.g. nitric oxide, epoprostanol, or milrinone).
  • Provide time for thrombolytic to circulate – Consider extended CPR (e.g. 60-90 minutes) to allow thrombolytic time to circulate.

 

 

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