Abstract

In this issue of EM Practice Guidelines Update, 3 current clinical practice guidelines that address the management of massive and submassive pulmonary embolism (PE) are reviewed. Venous thromboembolism (VTE) is a common disease that presents across a spectrum of severity. The evidence available to direct emergency clinicians confronted with patients suffering from hemodynamically significant PE is scarce, and the morbidity and mortality associated with severe PE is high, with acute PE leading to as many as 300,000 deaths annually.¹ The majority of deaths due to PE occur in the first hour.² Patients with severe, but not fatal, PE can experience disabling morbidity resulting from persistent right ventricular (RV) dysfunction. Recent evidence and opinion favors the use of reperfusion therapies, most importantly, intravenous (IV) thrombolysis, in certain patients with severe forms of PE. Providers caring for patients with large PE must therefore have an approach to guide their decision to administer or withhold these therapies, which offer the potential for great benefit but carry important risks.

Practice Guideline Impact

• Intravenous thrombolysis is recommended for most patients with massive (ie, hemodynamically unstable) PE.
• Identification of RV dysfunction is important to identify stable PE patients who are at higher risk for complications from PE and may benefit from thrombolysis.
• Use of thrombolytics in stable PE patients with RV dysfunction remains controversial, with an endorsement from the American Heart Association and the American College of Chest Physicians, but not the American College of Emergency Physicians.