Management of Pulmonary Embolus

Massive pulmonary embolus is defined as pulmonary embolus associated with hypotension (systolic BP <90mmHg) or other adverse features such as cardiac arrest. Thrombolysis is only currently indicated for massive PE. Life-long prophylaxis after first idiopathic PE should only be considered with the results of thrombolphilia testing and must be balanced against the risk of bleeding. Life-long prophylaxis remains debatable after first PE, except in the context of lupus anticoagulant. He should receive low molecular weight heparin and venous compression stockings for future long-haul flights.

There is an increased risk of cancer being detected within 6–12 months of a first episode of venous thromboembolism (VTE), particularly in those with no other risk factors and/or recurrent episodes. Previously unrecognised cancer, present in 7–12% of those with idiopathic VTE, can usually be detected by a combination of careful clinical assessment, routine blood tests, and chest radiography and, if these are satisfactory, the current consensus is that it is not appropriate to proceed to tests such as ultrasound, CT scanning or endoscopy.

Patients should not be anticoagulated with unfractionated heparin if they have lupus anticoagulant since this abnormality interferes with activated partial thromboplastin time (APTT) monitoring.

Reference

• See Medical Masterclass, Respiratory module, Clinical Presentation 1.5, for further discussion.

British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470-483.