Pulmonary embolism care plan

NHS Borders clinical guidelines
NHS Borders

Use of MDCalc recommended: this protocol required calculation of Level 2 Wells score, and s-PESI score.

Management in suspected PE phase

 

Treatment pending imaging (dose may change if PE confirmed):

Commence whilst awaiting scan if any delay

  • 1st choice – Apixaban 10mg BD (see contraindications - page 3)
  • 2nd choice – Dalteparin (see NHS Borders dose guidance-weight dependant)
  • 3rd choice – If eGFR <30 ml/min consider IV Heparin (discuss with senior)

If ambulatory:

  • Give worsening advice including side effects of anticoagulation
  • Complete AAU letter / UPR
  • Request CTPA
  • Book patient into AAU Ward Attenders as early slot as reminder to day team, and tell
    patient they will be phoned with a time to attend the next day
  • Day team then liaise with radiology, confirm time, and phone patient

 

Considerations for ambulatory treatment pending imaging:

Apixaban is contraindicated in:

  • Patients with active cancer
  • Intravenous drug users / alcohol misuse/significantly chaotic lifestyle
  • Pregnant or recently post-partum patients / breast feeding
  • Creatinine Clearance <30ml/min
  • CYP3A4 Liver enzyme inhibitors or inducers that may affect active drug levels: e.g. antifungal agents (other than fluconazole),
    clarithromycin, phenytoin, phenobarbitone, rifampicin, carbamazepine
  • Abnormal liver function significant enough to cause abnormal coagulation
  • Patient preference (i.e. after discussing options , DOAC is refused due to e.g. lack of reversal agent)
  • Known bleeding disorder
  • Age <18 years
  • Significant falls risk
  • Cognitive impairment without adequate carer support to ensure appropriate concordance with treatment

If not for Apixaban, and no specific contraindications to heparin therapy, use Low Molecular Weight Heparin (Dalteparin SC, doses as per local
guidance, or unfractionated if required).

 

Imaging phase

Ongoing management phase

Duration of treatment

Consider whether the PE is provoked or unprovoked, and whether there is a persistent risk factor:

Provoking factors that may be transient, or reversable

  • Major surgery with GA > 30 minutes
  • Pregnancy, particularly with caesarean delivery
  • Immobilisation > 3 days
  • Plaster cast to lower leg
  • Prolonged air/coach travel
  • Hormonal contraception
  • Hormonal replacement therapy
  • Active infective illness
  • Direct injury to leg
  • Renal disease – nephrotic syndrome.

Provoking factors that are permanent, or non-reversable

  • Collagen vascular disease
  • Active cancer or myeloproliferative conditions
  • Thrombophilia including Antiphospholipid disease
  • Provoked PE with transient or reversible risk factors is usually treated for three months (maybe longer depending on how long factor takes to address)
  • Provoked PE with permanent or non-reversible risk factors may require longer-term or lifelong anticoagulation. Discussion with  haematology is suggested for patients with thrombophilia and haematological conditions, and with oncology, for patients with cancer.
  • Pregnant patients should be discussed with obstetrics
  • Patients with nephrotic syndrome should be discussed and referred to renal

 

Approach to patients with no clear provoking factors

Consideration of underlying malignancy is paramount

  • All patient should have a clear history taken seeking features in keeping with malignancy
    such as weight loss, change of bowel habit, early satiety, dysphagia, PR bleeding,
    persistent cough, night sweats, and new lumps/bumps, and bone pain, and enquiry
    about whether they are up to date with national screening.
  • All patients should receive:
    • Bloods including FBC, U&E, LFT, PT, APTT
    • Urinalysis for haematuria and proteinuria (considering renal tract malignancy, and intrinsic renal disease
    • Physical examination, including consideration of PR and breast examination
    • Consideration of further imaging as guided by examination and tests – 2020
      guidance suggests no further imaging needed if no relevant signs or symptoms
  • Anticoagulation in first unprovoked PE should continue until review in respiratory clinic.

Editorial Information

Last reviewed: 31/12/2020

Author(s): Squires C Palik E.

Author email(s): eva.palik@borders.scot.nhs.uk.

Co-Author(s): Suarez C.

Related resources

• NICE guideline on Venous Thromboembolism 2020
• American College of Cardiology duration of anticoagulation post PE, 2019
• BTS guidelines 2018, due for review 2023.
• BMJ Best Practice