Maryland CC Project Sherner – Massive Pulmonary Embolism
Nov 19, 2021
Dr. John Sherner, a board-certified pulmonary and critical care physician and department chair, presents on massive pulmonary embolism. He covers definitions and risk stratification. He discusses thrombolysis dosing, catheter and surgical interventions, and ICU hemodynamic strategies. Special situations include pregnancy, clot-in-transit, and use of ECMO and PERT-style multidisciplinary decision-making.
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Massive Pulmonary Embolism Is A Spectrum
- Massive PE is best viewed as a spectrum from near-death CPR to mild sustained hypotension rather than discrete buckets.
- Risk-benefit shifts across the spectrum, so therapy should be individualized using physiology, clot burden, and signs of RV strain.
Follow Guidelines When Choosing Thrombolytics
- For PE with hypotension and low bleeding risk, give systemic thrombolytics; avoid lytics in stable patients without deterioration.
- If high bleeding risk or failed lytics and expertise exists, prefer catheter-directed therapy over no intervention.
Practical Thrombolytic Dosing And Heparin Management
- Use alteplase (tPA) regimens tailored to clinical context: 100 mg IV over 2 hours standard, 0.6 mg/kg over 15 minutes alternative, and 50 mg bolus for coding patients.
- Hold heparin during infusion at many U.S. centers and resume when PTT <2x normal; ESC recommends continuing heparin.