96 • All other combinations with V/Q scan requires further testing (ie, serial venous ultrasonography and pulmonary angiography) Treatment • Reserve TPA for patients with hemodynamic compromise (cardiogenic shock, persistent arterial hypotension, or both). If hemodynamically unstable, start on heparin drip immediately and prepare for thrombolytics. • Start patients with intermediate-risk or high risk PE on unfractionated heparin drip per protocol or enoxaparin at 1 mg/kg SC BID (can use fondaparinux in HIT patients). Patient needs to be on enoxaparin or fondaparinux eventually for outpatient bridge to long term anticoagulation therapy. These agents are generally preferred because they are easier to administer and are associated with lower rates of heparin-induced thrombocytopenia • If patient has HIT, can use argatroban or lepirudin drip instead of heparin drip (there are protocols for both). • Start patient on warfarin when heparin assay therapeutic or after 1 st does of LMWH; goal INR 2-3. Need to overlap treatment-usually 2-3 days after INR is therapeutic, and then can discontinue heparin. • Send patient to IR for IVC filter placement if contraindication to anticoagulation, treatment failure, or bleeding. References: 1. Fauci, AS, Martin, JB Braunwald, E. et al (Eds). Harrison’s Principles of Internal Medicine. 14 th Edition. McGraw Hill, New York, 1998. 2. Konstantinides, S. Acute Pulmonary Embolism. N Engl J Med 2008; 359:2804-2813. 3. Esteban, A, Frutos, F, Tobin, MJ, et al. A Comparison of Four Methods of Weaning Patients from Mechanical Ventilation. N Engl J Med 1995; 332:345-350. 4. Manthous, C, Schmidt, G, Hall, J. Liberation from Mechanical Ventilation: A Decade of Progress. Chest 1998; 114:886-901. 5. Schmidt, SL, Hyzy, RC. Overview of Mechanical Ventilation. In: UpToDate, Basow, D (Ed), UpToDate, Waltham, MA, 2009. 6. Tobin, MJ. Advances in Mechanical Ventilation. N Engl J Med 2001; 344:1986-96. 7. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301-8.
97 RADIOLOGY RADIOLOGY HINTS IF YOU’RE THINKING THIS: ORDER THIS FIRST Shortness of breath CXR* Chest pain CXR* Volume overload CXR* Obstruction Supine/upright KUB Acute abdomen, bowel perforation Abdomen obstructive series After subclavian line placement pCXR to r/o PTX DVT (pain, swelling) Lower extremity Doppler ultrasound PE (Consider checking ddimer +/- doing LE Doppler first) -- CTA chest (CT chest PE protocol) AMS CT head Carotid stenosis Carotid Doppler ultrasound Stroke CT head WITHOUT contrast, then MRI brain
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