Acute Pulmonary Embolism Clinical Pathway – Emergency Department, ICU and Inpatient

Emergency Department, ICU, and Inpatient Clinical Pathway
for Children with Suspected Acute Pulmonary Embolism

Goal and Metrics
Provider Resources
Child with Suspected Acute Pulmonary Embolism (PE)
Exclusions
Children in CCU, CPRU, CICU

Transfer from Outside Hospital

  • Recommend OSH images are uploaded
  • Medical command/PICU should consult Hematology for initial anticoagulation recommendations
  • Do not activate PERT prior to transfer unless high-risk
How to Activate PERT After PE Diagnosis
Stable Hemodynamics
  • Hematology consult
  • Hematology will activate PERT as necessary
Unstable Hemodynamics
  • Call ICU (CAT, CODE or ED Tier)
  • PICU or Hematology will activate PERT
 
 

History and Physical

Review Risk Factors for PE

 
 
 
 
Hemodynamically Unstable
 
 

Diagnostic Evaluation

  • Laboratory
    • CBC, CMP
    • Troponin, BNP
    • D-dimer, PT/INR, PTT, fibrinogen
    • Type and screen
    • VBG or ABG with lactate
  • ECG
  • CTA PE protocol, IV catheter size
 
 
 
 
CTA with no PE
Assess for other causes
CTA with PE

Initiate anticoagulation with Hematology Consult

Enoxaparin vs. Unfractionated Heparin (UFH)
 
 
Evaluate for right heart dysfunction
  • All of the following:
    • CTA: no RV dilation and small clot burden
    • BNP and normal troponin
  • ≥ 1 of the following:
    • Sustained tachycardia
    • Supplemental oxygen requirement
    • CTA: RV dilation, large clot burden
    • BNP > 100 or troponin > ULN
  • Cardiac arrest
  • Shock
  • Sustained hypotension
 
 
 
 
 
 

Echo Protocol

Comprehensive Pulmonary Hypertension Protocol
Echo within 24 hrs
Urgent Echo (< 6 hrs)
Immediate Echo
Echo should not delay management in high-risk PE
 
 
 
 
 
 
Pulmonary Embolism Risk Stratification
 
 
 
 
 
 
Low Risk PE
  • Clinical, Diagnostic Criteria
    • Normotensive
    • CTA: no RV dilation
    • BNP < 100 pg/mL
    • Troponin < ULN
    • Normal echo
  • Consult
    • Hematology
    • Cardiology for echo
  • Treatment
  • Disposition
    • Inpatient unit
Ultrasound of lower extremities and any other extremities that are symptomatic or have a central venous catheter in place
Decompensation
 
 
Intermediate Risk PE
  • Clinical, Diagnostic Criteria
  • Consult
    • Hematology, who will activate PERT
    • Cardiology consult team
  • Treatment
    • Anticoagulation with enoxaparin or UFH
    • Consider systemic or catheter-directed tPA on a case-by-case basis in discussion with PERT
  • Disposition
    • PICU
    • A subset may be eligible for inpatient care after Hematology consult
Ultrasound of lower extremities and any other extremities that are symptomatic or have a central venous catheter in place
Decompensation
 
 
High-Risk PE
  • Clinical, Diagnostic Criteria
    • Cardiac arrest
    • Sustained hypotension or shock
  • Consult
    • PICU/Hematology, who will activate PERT
    • Cardiology consult team
  • Treatment
    • Consider systemic or catheter-directed tPA if no contraindications
    • +/- anticoagulation with UFH
  • Consider Additional Interventions
    • VA-ECMO
    • Surgical thrombectomy
  • Disposition
    • PICU
Ultrasound of lower extremities and any other extremities that are symptomatic or have a central venous catheter in place