CCM Notes
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ICU Essentials
DVT & Pulmonary Embolism
Risk Stratification · Wells Score · Anticoagulation · Thrombolysis Algorithm
📊 Wells Score for PE — Pre-Test Probability
Clinical signs/symptoms DVT+3
PE most likely diagnosis (or equally likely)+3
HR > 100 bpm+1.5
Immobilisation > 3 days OR surgery within 4 wks+1.5
Prior DVT or PE+1.5
Haemoptysis+1
Malignancy (treatment within 6 months / palliative)+1
Low <2
Mod 2–6
High >6
✶ Two-level: ≤4 = PE unlikely (get D-Dimer) | >4 = PE likely (CTPA directly)
🔺 Haemodynamic Risk Stratification (ESC 2019)
High Risk
SBP <90
or drop ≥40 mmHg >15 min
Immediate reperfusion
Consider thrombolysis
Intermediate-High
RV dysfn
+ Troponin/BNP ↑
Anticoag + monitor
ICU admission
Intermediate-Low
PESI III–IV
RV or Troponin normal
Anticoag + admit
Short obs
Low Risk
PESI I–II
Hemodynamically stable
Early discharge
Oral anticoag
⚕ Treatment Algorithm — Confirmed PE
1
High-Risk PE (haemodynamic instability): Systemic thrombolysis — Alteplase 100 mg IV over 2h. If CI: surgical embolectomy or catheter-directed
2
Anticoagulation (all non-high-risk): Start immediately. LMWH (Enoxaparin 1 mg/kg SC q12h) OR UFH 80 U/kg bolus + 18 U/kg/hr if renal impairment
3
Long-Term Anticoag: DOACs preferred — Rivaroxaban 15 mg BD×21d then 20 mg OD OR Apixaban 10 mg BD×7d then 5 mg BD
4
Duration: 3 months (provoked) | 6 months (unprovoked first) | Indefinite (cancer, recurrent, antiphospholipid)
5
IVC Filter: Only if anticoag absolutely contraindicated (active major bleeding). Not routine. Reassess regularly for removal.
💊 Thrombolysis — Eligibility
✅ Indications (High-Risk PE)
• Cardiac arrest from PE
• SBP < 90 mmHg ≥ 15 min
• Cardiogenic shock not responding
❌ Absolute Contraindications
• Prior intracranial haemorrhage
• Structural intracranial disease
• Ischaemic stroke <3 months
• Active internal bleeding (not menses)
• Major surgery/trauma <3 wks
🦵 DVT — Diagnosis & Treatment
Diagnosis
• Wells DVT score (high ≥3 → USDVT directly)
• D-Dimer (if low prob): ELISA sensitivity >99%
• Compression USS — gold standard
Treatment
• Proximal DVT: anticoag 3–6 months
• Distal DVT (symptomatic): 6–12 weeks
• Rivaroxaban 15 mg BD × 3wk → 20 mg OD
• Compression stockings — symptom relief
• Thrombolysis: only massive/limb-threatening
🚨 High-Risk PE — Immediate Actions (First 10 Minutes)
⚡O₂: High-flow via NRB, target SpO₂ >94%. Intubate if failing — use ketamine, avoid propofol
⚡Fluids: Max 500 mL cautious bolus — RV is preload dependent but overfill = death
⚡Vasopressor: Noradrenaline for RV support. Dobutamine if RV failure/low output
⚡UFH: Start immediately — 80 U/kg bolus + 18 U/kg/hr whilst preparing thrombolysis
⚡Thrombolysis: Alteplase 100mg/2h. Stop UFH during. Restart when aPTT < 80 sec after
⚡ECMO: If refractory cardiac arrest or thrombolysis contraindicated — call cardiothoracic early