Ep 204 High Risk Pulmonary Embolism Management

This podcast delves into the complexities of managing high-risk pulmonary embolism (PE) patients, emphasizing the importance of rapid risk stratification and tailored treatment strategies. The discussion highlights the "spiral of death" in PE, where RV failure leads to decreased cardiac output and worsening ischemia. Key recommendations include avoiding over-intubation, careful PEEP management, and judicious fluid administration. The experts advocate for norepinephrine as a first-line vasopressor, with vasopressin as a secondary option, and discuss the nuances of thrombolysis, weighing the benefits against bleeding risks. The podcast also explores catheter-directed thrombolysis and surgical thrombectomy as alternatives to systemic lytics in select cases.

Outlines

Part 1: Introduction, Pathophysiology, and Definitions

Part 2: Resuscitation, Airway, and Hemodynamics

Part 3: Thrombolysis and Advanced Interventions

Part 4: Medication Dosing and Adjunctive Therapies

Part 5: Special Scenarios and Systems of Care

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Emergency Medicine Cases

Part 1: Introduction, Pathophysiology, and Definitions

High-Risk Pulmonary Embolism: Introduction, Mortality Rates, and Case Evolution

Pathophysiology of High-Risk PE: The Spiral of RV Failure and Systemic Hypotension

Defining and Subdividing High-Risk PE for Effective Management

Part 2: Resuscitation, Airway, and Hemodynamics

Goals of Management in Peri-Arrest PE: ABCs with RV-Focused Caveats

Optimizing Oxygenation and Ventilation in High-Risk PE: High Flow Nasal Cannula and Avoiding Intubation

Intubation Strategies and Blood Pressure Support in Peri-Arrest PE Patients

Part 3: Thrombolysis and Advanced Interventions

Thrombolysis Decisions: Balancing Systemic Lysis with Catheter-Directed Therapies

Assessing Bleeding Risk and Shared Decision-Making in High-Risk PE

Evidence for Non-Systemic Lysis Procedures: Surgical and Mechanical Thrombectomy

Practical Approaches to Non-Systemic Lysis: Patient Selection and Risk Mitigation

Part 4: Medication Dosing and Adjunctive Therapies

Lytic Dosing Strategies: Cardiac Arrest vs. Peri-Arrest and High-Risk Patients

Anticoagulation Strategies: IV Heparin vs. Low Molecular Weight Heparin

Managing Acidosis and Pulmonary Vasodilation in High-Risk PE

Part 5: Special Scenarios and Systems of Care

Managing Cardiac Arrest with Suspected PE: History, Rhythm, and Prognostic Factors

Pulmonary Embolism Response Teams (PERTs): Evidence, Costs, and System-Level Considerations

Key Takeaways and Resources for Managing High-Risk PE Patients

Ep 204 High Risk Pulmonary Embolism Management

Emergency Medicine Cases

Part 1: Introduction, Pathophysiology, and Definitions

00:00High-Risk Pulmonary Embolism: Introduction, Mortality Rates, and Case Evolution

High-Risk Pulmonary Embolism: Introduction, Mortality Rates, and Case Evolution

04:17Pathophysiology of High-Risk PE: The Spiral of RV Failure and Systemic Hypotension

Pathophysiology of High-Risk PE: The Spiral of RV Failure and Systemic Hypotension

07:36Defining and Subdividing High-Risk PE for Effective Management

Defining and Subdividing High-Risk PE for Effective Management

Part 2: Resuscitation, Airway, and Hemodynamics

11:42Goals of Management in Peri-Arrest PE: ABCs with RV-Focused Caveats

Goals of Management in Peri-Arrest PE: ABCs with RV-Focused Caveats

16:23Optimizing Oxygenation and Ventilation in High-Risk PE: High Flow Nasal Cannula and Avoiding Intubation

Optimizing Oxygenation and Ventilation in High-Risk PE: High Flow Nasal Cannula and Avoiding Intubation

25:36Intubation Strategies and Blood Pressure Support in Peri-Arrest PE Patients

Intubation Strategies and Blood Pressure Support in Peri-Arrest PE Patients

Part 3: Thrombolysis and Advanced Interventions

32:38Thrombolysis Decisions: Balancing Systemic Lysis with Catheter-Directed Therapies

Thrombolysis Decisions: Balancing Systemic Lysis with Catheter-Directed Therapies

37:35Assessing Bleeding Risk and Shared Decision-Making in High-Risk PE

Assessing Bleeding Risk and Shared Decision-Making in High-Risk PE

44:00Evidence for Non-Systemic Lysis Procedures: Surgical and Mechanical Thrombectomy

Evidence for Non-Systemic Lysis Procedures: Surgical and Mechanical Thrombectomy

49:13Practical Approaches to Non-Systemic Lysis: Patient Selection and Risk Mitigation

Practical Approaches to Non-Systemic Lysis: Patient Selection and Risk Mitigation

Part 4: Medication Dosing and Adjunctive Therapies

57:38Lytic Dosing Strategies: Cardiac Arrest vs. Peri-Arrest and High-Risk Patients

Lytic Dosing Strategies: Cardiac Arrest vs. Peri-Arrest and High-Risk Patients

1:03:57Anticoagulation Strategies: IV Heparin vs. Low Molecular Weight Heparin

Anticoagulation Strategies: IV Heparin vs. Low Molecular Weight Heparin

1:09:05Managing Acidosis and Pulmonary Vasodilation in High-Risk PE

Managing Acidosis and Pulmonary Vasodilation in High-Risk PE

Part 5: Special Scenarios and Systems of Care

1:12:18Managing Cardiac Arrest with Suspected PE: History, Rhythm, and Prognostic Factors

Managing Cardiac Arrest with Suspected PE: History, Rhythm, and Prognostic Factors

1:16:38Pulmonary Embolism Response Teams (PERTs): Evidence, Costs, and System-Level Considerations

Pulmonary Embolism Response Teams (PERTs): Evidence, Costs, and System-Level Considerations

1:20:44Key Takeaways and Resources for Managing High-Risk PE Patients

Key Takeaways and Resources for Managing High-Risk PE Patients