This post contains the excerpt, Coding A PE Patient, from Dr. Josh Farkas‘ IBCC 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.
