HMC PE Algorithm V1.0 6/25/2018 SUSPECTED PE

Hemodynamically Stable2 AND Wells ≤ 4?

< 500 ng/ml OR less than age-adjusted value1

≥500 AND greater than age-adjusted value

Negative

PE Excluded

Positive

PE Confirmed

Candidate for CT Chest PE?3

PE MORE LIKELYPE UNLIKELY

Low Likelihood Hemodynamically

Significant PE

Possible PE

Shock?

Any Risk for Sub-massive PE?• EKG w/RV strain• Trop I > 0.04• BNP > 90• CT PA RV/LV ratio > 0.9• POC US w/RV enlarge/dysfxn• PESI1 Class III or higher

Massive PE

Sub-Massive PE Standard Risk PE

Footnotes1. See appendix and glossary2. SBP>90 without vasopressors3. If not candidate for CT-PA (e.g. low eGFR, pregnant, contrast allergy), consider V/Q,

serial LE duplex or MRA-PE4. Trans-Thoracic Echocardiogram: Must page Echo Fellow on-call to arrange.5. RV Strain documentation on TTE read: “Severe RV enlargement”, “Severe RV

systolic dysfunction”, “Septal flattening”6. PERT – PE Response Team (see next page for details)7. LMWH or DOAC. IV Heparin if considering thrombolysis.

Stat TTE for

Evidence of RV strain?5

Yes

No Further Testing for PE needed

No

Yes

Possible Massive

PE

Shock?

Possible Sub-Massive

PE

No

• CONSIDER ANTI-COAGULATION• STAT: TTE, LE Duplex

Evidence for RV strain5 OR DVT?

Any risks for hemodynamically significant PE?• ECG w/ RV strain• Trop I > 0.04• BNP > 90• RV enlarge/dysfxn by POC US• SBP<90 or Vasopressors

No

Yes

YesNo

No

No

Yes

Yes

Yes

Yes No

No

• STAT: ECG, TROP I, BNP• CONSIDER POC US• CONSIDER ANTI-COAGULATION

• D-DIMER

• START ANTI-COAGULATION

• CONSIDER ANTI-COAGULATION7

• STAT: TTE, LE DUPLEX

• STAT: CT Chest PE

• STAT: TTE4

• RISK ASSESS (WELLS, PERC1)

Ambulatory AND Wells ≤ 1 AND PERC negative?

Yes No

• Safe for Acute CareFloor or Home withHestia Rule1

• Start Anti-Coagulation7

• Call PERT6

• Consider ICU Admit• Start Anti-Coagulation7

• Consider other dx if “Possible”• Consider Systemic rtPA

• Consider other dx• Consider calling PERT6

• If residual suspicionfor VTE consideranticoagulation

• Consider V/Q scanand/or serial LEduplex

• Call PERT6

• ICU Admit• Start IV Heparin• STAT TTE4 if not done• Start systemic rtPA if no

contraindications• Consider Catheter-

Directed Thrombolysis (IR)• Consider other dx if

“Possible”

PE Response Team (PERT)

Activation to be initiated by ED, primary service (ICU

or Acute Care), or code leader. Call “222” and ask for PERT Attending.

PERT Attending will triage case to either:

Modified PERT Response

Teleconference with:

•Prim

ary Service Representative (attending, fellow, senior

housestaff)•

MICU

Attending/Nocturnistand Fellow

•ECLS Attending or Fellow

•CCU

Attending

Full PERT ActivationBedside M

eeting with:

•Prim

ary Service Representative (attending, fellow, senior

housestaff) or Code Leader if appropriate•

MICU

Attending/Nocturnistand Fellow

•ECLS Attending or Fellow

Bedside Meeting or Teleconference w

ith:•

CCU Attending

PERT will com

e to recomm

endation for m

anagement/therapy and PERT Attending w

ill write PERT

Powernote

documenting this recom

mendation.

Wells Score:

•N

o better alternative dx (3 pts)•

Symptom

s of DVT (3 pts)•

HR > 100 (1.5 pts)

•Im

mobilization > 3d or surgery in <4 w

ks(1.5 pts)

•H

xof DVT or PE (1.5 pts)

•H

emoptysis (1 pt)

•M

alignancy (1 pt)PE risk: U

nlikely ≤4, Likely >4

PERC–

negative if all true•

Age < 50•

HR < 100 bpm

•SpO

2 > 95%•

No hem

optysis•

No estrogen use

•N

o h/o DVT/PE•

No unilateral leg sw

elling•

No surgery/traum

a within last 4 w

eeks

Age Adjusted D-D

imer if ≥ 50 yrs

old•

Calculated as age*10Ex: 88 y/o threshold for excluding VTE is <880 ng/m

l

Glossary

CT PA –CT Chest PE Protocol

Trop I –Troponin I

BNP –

Brain Natriuretic Peptide

POC U

S –Point-of-care U

ltrasoundTTE –

Transthoracic EchocardiogramIV U

FH-

Intravenous Unfractionated

Heparin

DO

AC–

Direct O

ral Anticoagulant (e.g. Rivaroxaban, D

abigatran)LM

WH

–Low

Molecular W

eight Heparin

(e.g. Enoxaparin)rtPA

–Recom

binant Tissue Plasminogen

ActivatorCDT

–Catheter D

irected Thrombolysis

(mechanical or chem

ical)

Appendix