Network Five: Pulmonary embolism

Network Five: Episode 11 – Pulmonary embolism

Participants: Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Naveendran Rajendran, Harry Hong, Samoda Wilegoda Mudalige, Kit Rowe and Caroline Tyers.  

Part 1

This episode is all about pulmonary embolism (PE)! In this first segment, we explore the potential use of the age-adjusted d-dimer in the risk stratification of patients presenting with a possible PE. Presenter: Naveendran Rajendran – ED Resident at Westmead Hospital. 

• Robert-Ebadi H et al. Impact of the Age-Adjusted D-Dimer Cutoff to Exclude Pulmonary Embolism: A Multinational Prospective Real-Life Study (the RELAX-PE Study). Circulation. 2021 May 4;143(18):1828-1830.

Part 2

In this second segment on pulmonary embolism (PE), we talk to Dr Jimmy Chien, a senior respiratory physician, about developing the PE response team (PERT) at Westmead Hospital. Then we discuss the potential role of VA-ECMO in high-risk PE. The interlude segment is presented by senior emergency physician Dr Kevin Lai.

• Scott JH et al. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 May 1;49(5):760-769
• Piazza G et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015 Aug 24;8(10):1382-1392
• Herzallah K et al. Saddle pulmonary embolism successfully managed by thrombus aspiration followed by ultrasound-enhanced catheter-directed thrombolysis. Journal of the American College of Cardiology, 2020; 75(11): 2445. 

Take-Home Points:

• In addition, the length of stay for these patients managed by the PERT team has been reduced from 13 days pre-PERT to around 8.5 days.  
• The PERT team facilitates high-level nuanced conversations dependent on the clinical judgment, experience, and knowledge of the specialists involved. 
• The development of this PERT team has resulted in improved outcomes for PE patients, and more streamlined care for these patients while in the emergency department and on the ward.  

Part 3

In this final segment of the series on pulmonary embolism (PE), we take a close look at the YEARS algorithm for PE. The interlude segment is presented by respiratory physician Dr Bristi Roy.

• van der Pol LM et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149
• van der Hulle T et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul 15;390(10091):289-297.

Take-Home Points:

• This provides a framework for assessing patients, particularly in the first and second trimesters of pregnancy (and may aid in safely excluding PE without CTPA for low-risk patients). 
• However, in high-risk patients, pursuing a scan remains the most appropriate approach.  

These episodes were produced with help of HETI’s Emergency Medicine Training Network 5. Please send us an email to let us know what you thought. You can contact us at [email protected]