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Figuring out how to manage patients with acute pulmonary embolism isn’t always straightforward. Should you thrombolyse a pregnant patient with massive PE? What about the 1 week post op patient? Amal Mattu gives his thoughts and the current evidence on these questions (and more!).
richard g., jr - December 13, 2015 4:14 PM
Great conversation. During the segment on thrombolysis in pregnancy I found myself thinking about a nightmare scenario and wondering what I would do. The scenario is a pulseless patient with viable pregnancy who arrested in the ED, time zero. The diagnosis of massive PE is clear ( swollen leg on physical, bedside echo findings consistent with PE, etc...) thrombolysis, OR perimortem c-section, OR lysis and then section if no ROSC within the 5-7 minute range?
Sitting here comfortably in my house, thankful i'm not actually living that nightmare, I think I would attempt lysis and if no ROSC then advance to the bloody nightmare of perimortem. If lysis is successful then both patients have a chance and if unsuccessful then both die unless you can deliver the fetus. Starting with peri-mortem is less favorable to me because you may deliver the baby but mom still has the embolus, it seems you are aborting attempt at salvage of mom early in resuscitation by selecting this option first. Very curious to hear what others would do/have done?
Tyler W., Winders - December 15, 2015 6:38 PM
I loved every part of this segment except the IVC filter placement recommendations. The comments about when to place an IVC filter are fairly outdated. A 20-40% complication rate is not insignificant. Couple this with a low retrieval rate in spite of the fact that the guidelines are being actively changed to reflect that only folks with contra-indication to anticoagulation should receive IVC filters (probably because they were all excluded from the trials), and we should seriously reconsider our stance on IVC filters. PREPIC 1 and PREPIC 2 should have laid all questions to rest. IVC filters kill people and don't fix even the highest risk PEs, the only question left before the door should be closed on IVC filters period is "Do IVC filters benefit those with contraindications to anticoagulation?"