Monitoring and Management of Acute Pulmonary Embolism
Acute pulmonary embolism (PE) is a commonly encountered medical condition that can lead to right ventricle compromise, systemic hypotension, and hemodynamic collapse. Early recognition of intermediate and high-risk PEs can help to reduce the likelihood of worsening clinical status. The diagnosis of PE can be aided by the use of computed tomography angiography (CTA), transthoracic echocardiogram (TTE), and laboratory testing in the form of cardiac troponin, brain natriuretic peptide (BNP), and d-dimer. The clinical deterioration that can be associated with PEs is driven by a combination of thrombus formation as well as vasoconstriction within the pulmonary vasculature. These two elements work in conjunction to increase right ventricle (RV) afterload, to increase pulmonary vasculature resistance, and to decrease RV stroke volume. In the setting of increased pressure, the RV dilates resulting in decreased cardiac output as the interventricular septum shifts into the left ventricle (LV) cavity. Clot burden can be addressed with anticoagulation in low-risk cases; however intermediate and high-risk cases may involve systemic thrombolysis, catheter-directed therapy, surgical embolectomy, or extracorporeal membrane oxygenation (ECMO). Along with addressing the clot, in the setting of hypotension, vasopressors and inotropic support may be needed to maintain RV perfusion.
