EMU 365: PE Thrombolysis in 2018

The final EMU365 video from EMU2018 features Dr. Amit Shah who discusses decision making and dosing around the use of thrombolytics in PE in the context of cardiac arrest, massive PE and submassive PE; the controversy around using half dose alteplase, and nuanced decision making around which patients with submassive PEs should be thrombolysed.

Massive PE

  • Acute PE is cause for hypotension
  • SBP <90 for > 15 min
  • HR <40, sustained bradycardia due to shock
  • SBP 40 points from from baseline > 15 min

Dosing: Massive PE


  • Alteplase 10 mg IV push, 90mg over 2 hours
  • LMWH
  • Controversial: alteplase 50 mg IV over 2 hours (Wang, Chest 2010), lower risk of bleeding with this strategy (consider in those with higher bleeding risk)

High Bleeding risk or age >75:

  • Consider catheter directed thrombolysis (CDT) if they can tolerate time to treatment

Dosing: Cardiac Arrest

  • Alteplase 50mg IV push over 60 seconds (“PEAPETT” study)
  • LMWH

Submassive PE

  • Acute PE with concomitant:
    • RV enlargement on ultrasound or CT (RV:LV > 0.9)
    • Elevated troponin
    • Acute ECG changes

When and who to thrombolyse with submassive PE

  • Do not thrombolyse patients who look well and have stable vitals, regardless of laboratory findings or CT clot burden
  • Pick only the sickest of the submassives to lyse
    • Factors to consider as these are all independent risk factors for mortality: RV strain on US/CT, troponin, BP, pulse, shock index, age, hypoxia, ECG changes, lactate, BNP, presence of DVT, cardiac reserve (CHF/COPD)

Speaker Bio

Dr. Amit Shah is an Emergency Physician and award winning educator hailing from Western University, London, Canada.  He splits his emergency medicine practice between academic and community sites, and has previously worked as a family and emergency physician in rural and remote locations.   His interests include procedural sedation, thrombolysis for pulmonary embolus, ED efficiency and service, and procedures in the ED.

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