Therapeutic Handbook - GGC Prescribing

Initial management• Seek immediate senior advice as patient may need transfer to CCU / ICU / HDU / Resus• Heparinise with IV unfractionated heparin bolus (5,000 units) then IV infusion (18 units/kg/houradjusted to maintain APTT ratio of 1.8 - 2.8) - see page 76.• Perform urgent CTPA or cardiac ECHO (if CTPA not possible / not available)Cardiovascular System• O 2• IV fluids and inotropic support• If pregnant, inform on-call obstetric team immediately for consideration of early delivery• If there is persistent hypotension (SBP < 90 mmHg) and either CTPA confirms PE, cardiac ECHOdemonstrates RV dilatation / dysfunction or patient is in peri-arrest, then consider thrombolysisas follows:- Alteplase IV 10 mg over 1 - 2 minutes followed by 90 mg over 2 hours (max 1.5 mg/kg if< 65 kg); if this is not available, consider using local regimen for MI (unlicensed for PE).- Continue heparin to maintain APTT ratio 1.8 - 2.8If thrombolysis contraindicated, consider percutaneous catheter fragmentation or surgicalembolectomy. Be aware that when considering thrombolysis the risk of major haemorrhage issignificantly increased in the older patient.Diagnostic algorithm for out-patients with suspected DVTPatients with chronic heart failure or suspected bilateral DVT and patients at extremes of weightor with renal impairment (i.e. CrCl < 30 ml/minute) preventing the safe use of LMWH, may not besuitable for out-patient investigation and management of suspected VTE.Table 1 – Wells Clinical ScoreActive cancer (treatment ongoing, within previous 6 months or palliative) 1Paralysis, paresis or recent plaster immobilisation of lower extremities 1Recently bedridden for > 3 days or major surgery within 12 weeks 1Localised tenderness along distribution of deep venous system 1Entire leg swollen 1Calf swollen by > 3 cm compared to asymptomatic leg (10 cm below tibial tuberosity) 1Pitting oedema (greater in symptomatic leg) 1Collateral superficial veins (non-varicose) 1Previously documented DVT 1Alternative diagnosis as likely or greater than that of DVT -2TOTAL:Score < 2: DVT unlikely Score > 2: DVT possibleFrom The New England Journal of Medicine, Philip S. Wells, David R. Anderson, Marc Rodger, et al., Evaluation of D-Dimerin the Diagnosis of Suspected Deep-Vein Thrombosis, 349(13), 1227-35. Copyright © (2013) Massachusetts Medical Society.Adapted with permission from Massachusetts Medical Society.See flow chart on next pagePage 72