Dr. Sara Crager leads a deep dive on hemodynamic management of massive pulmonary embolism. 

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Ian C. -

Excellent. Made a complex subject clear.

Adan A. -

Excellent and entertaining presentation.
In the treatment portion you mentioned that Vasopressin is your go-to pressor in PE, followed by Epi.
How are dosing each of them? At what limit of Vaso you decided to add Epi and how do you titrate?

Thank you


James O. -

Thank you for another great lecture. The ICU fundamental series has been fantastic. I'm curious to hear your thoughts on a rapid diagnostic approach for PE in cardiac arrest given RV and IVC dilation occur regardless of the cause of arrest. How does the etCO2 gradient change in arrest and is there still an exaggerated etCO2 gradient in arrest due to a PE? Are there other rapidly available data points (lab values, US views, etc.) outside of history and physical that might lead you to suspect PE as the etiology of an arrest?

Metin O. -

Excellent lecture. As @goodCPR said, what are the doses of Vasopressin and Epi? When do you transition to Epi? Thank you

Michael P. -

Any chance that a list of the papers referenced in the lecture could be posted in the downloads section?

Ugne C. -

Wow. That was one of the most informative pieces of information I have gained in awhile. I even had a conversation with my hospitalist in regards to this type of management. I agree that we have hurt people with massive PEs in the past and a few have died from mis-management. This is great. Thank you so much.

Mansoor A. -

Wonderful lecture, definitely helped. Working in a rural ER, saw patient few days after going through this lecture, unfortunately due to kidney function was unable to confirm suspicion of pulmonary emboli, and family didn't want patient transferred to higher level of care. Patient was tachycardic, dyspnea, requiring oxygen, clear lungs otherwise and low blood pressure, suspicion was hight for pulmonary embolism. Dimer also came back >5,000 after diluation. Did the inhaled nitroglycerin, we don't have vasopressin and so did levophed, was light with volume and avoided intubation. Started Lovenox. That was 4 days ago, patient discharging today, improved and back to baseline. CT scan a few days later showed large pulmonary saddle embolism and ultrasound confirmed bilateral large DVT's (neither ordered by me).

I request that a downloadable summary is provided with these HD videos as a quick summary of key points, as it comes in handy while seeing patients.

Thank you !!!

Charles P., M.D. -

Just listened to this great series about 2 months ago. Sounds like you did a great job in your case. Would be curious to hear from Sara what additional info would she have wanted to justify giving TPA systemically in this case.

Mat G. -

Here are the papers she referenced:

1. Fikry D, Ramadan M, Elhadedy M, Hussein H. Comparison of hemodynamic effects of inhaled milrinone and inhaled nitroglycerin in patients with pulmonary hypertension undergoing mitral valve surgery. Res Opin Anesth Intensive Care. 2017;4(1):35. doi:10.4103/2356-9115.202698

2. Mandal B, Kapoor PM, Chowdhury U, Kiran U, Choudhury M. Acute hemodynamic effects of inhaled nitroglycerine, intravenous nitroglycerine, and their combination with intravenous dobutamine in patients with secondary pulmonary hypertension. Ann Card Anaesth. 2010;13(2):138-144. doi:10.4103/0971-9784.62946

3. Goyal P, Kiran U, Chauhan S, Juneja R, Choudhary M. Efficacy of nitroglycerin inhalation in reducing pulmonary arterial hypertension in children with congenital heart disease. Br J Anaesth. 2006;97(2):208-214. doi:10.1093/bja/ael112

4. Yurtseven N, Karaca P, Kaplan M, et al. Effect of nitroglycerin inhalation on patients with pulmonary hypertension undergoing mitral valve replacement surgery. Anesthesiology. 2003;99(4):855-858. doi:10.1097/00000542-200310000-00017

5. Sablotzki A, Starzmann W, Scheubel R, Grond S, Czeslick EG. Selective pulmonary vasodilation with inhaled aerosolized milrinone in heart transplant candidates. Can J Anaesth. 2005;52(10):1076-1082. doi:10.1007/BF03021608

6. Denault AY, Bussières JS, Arellano R, et al. A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients. Can J Anaesth. 2016;63(10):1140-1153. doi:10.1007/s12630-016-0709-8

7. Haddad AYDF, Nguyen YLAQN, Lévesque S, et al. Pilot Randomized Controlled Trial of Inhaled Milrinone in High-Risk Cardiac Surgical Patients. 2014. doi:10.4172/2161-1076.1000192

Mel H. -

Thanks Matt!!

Michael S. -

Excellent lecture, thank you.

Mark P., Dr. -

Thanks, that was great. If you're using nebulised nitric oxide, I got the dose of 5mL over 15 mins, but how long do you keep going for? Do you just keep doing it continuously back to back?

James Bryan F. -

Great lecture. Thanks

David K. -

These lectures are great....more please!

David M. -

Thank you for this great series, please make more!

Evan F. -

This is fantastic! Excited to see more of the series!

Marie-Claude C. -

Excellent lecture, more of these, written summary please. Thanks for your excellent work.

Felipe A. -

Awesome lecture! If the patient has arrested would you still not intubate?

Bahadir A., MD -

Many thanks for your great presentation! Id like to ask you a question. in 2019 Europe PTE management guideline recomended first line vasoactive agents are NE and Dobutamine . Their doses :
Norepinephrine, 0.2-1.0 mg/kg/min
Dobutamine, 2-20 mg/kg/min
Vazopressin and Epinefrin are not listed in there .

Ali Hussein Y. -

Fantastic lecture!

Charles P., M.D. -

Addressed to Sara Crager

Really loved the PE series. Based on that am trying to set in place in our institution inhaled NTG or Milrinone. Am working with our PharmD, and he asked if I knew of anyone who had worked out these issues logistically. Does your ED or ICU have a process/protocol for using these inhaled agents??
Chuck - 37 year ED veteran
PS Keep up the great work - really looking forward to Part 2 of the Fluid management series

Hana D. -

Best lectures ever!!! Love it
super helpful.

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