Gossage proposed an algorithm for the management of massive pulmonary embolism based on the indications, benefits and risks of the different therapeutic options..
Parameters:
(1) indications for thrombolysis
(2) benefits vs risk thrombolysis
(3) benefits vs risk embolectomy (and availability)
(4) risk of death from recurrent pulmonary embolism
(5) contraindications for anticoagulation
|
Situation |
Therapy |
|
indications for thrombolysis AND benefits > risk |
thrombolysis |
|
indications for thrombolyis AND benefits < risk, AND benefits for embolectomy > risks |
embolectomy |
|
indications for thrombolysis AND benefits < risk, AND benefits for embolectomy < risks AND anticoagulation not contraindicated |
anticoagulation plus inferior vena cava filter |
|
indications for thrombolysis AND benefits < risk, AND benefits for embolectomy < risks AND anticoagulation is contraindicated |
inferior vena cava filter |
|
thrombolytic therapy not indicated AND patient is at risk for death from recurrent PE AND anticoagulation is not contraindicated |
anticoagulation plus inferior vena cava filter |
|
thrombolytic therapy not indicated AND patient at risk for death from recurrent PE AND anticoagulation is contraindicated |
inferior vena cava filter |
|
thrombolytic therapy not indicated AND patient not at risk for death from recurrent PE AND anticoagulation is not contraindicated |
anticoagulation |
|
thrombolytic therapy not indicated AND patient not at risk for death from recurrent PE AND anticoagulation is contraindicated |
inferior vena cava filter |
Indications for thrombolysis:
(1) shock
(2) systolic blood pressure < 90 mm Hg
(3) recent cardiac arrest
(4) severe respiratory failure (PaO2-to-FIO2 ratio < 150)
(5) severe right ventricular dysfunction on echocardiography
(6) right ventricular dysfunction and (metabolic acidosis or mixed venous oxygen saturation < 55%)
Contraindications to thrombolysis:
(1) neurosurgical treatment within 1 month
(2) ischemic stroke within 1 month
(3) active intracranial disease
(4) active internal bleeding
(5) diastolic blood pressure > 110 mm Hg
(6) systolic blood pressure > 200 mm Hg
(7) surgery, trauma or organ biopsy within 2 weeks
Relative contraindications to thrombolysis:
(8) puncture of noncompressible vessel within 48 hours
(9) recent and prolonged cardiopulmonary resuscitation
(10) pericarditis
(11) hemorrhagic retinopathy
(12) coagulopathy
(13) platelet count < 75,000 per µL
(14) pregnancy
Specialty: Pulmonology
ICD-10: ,
