1.Admit to:
2. Diagnosis: Pulmonary embolism
3. Condition:
4. Vital Signs: q1-4h. Call physician if BP >160/90,<90/60; P >120, <50;
R >30, <10; T >38.5°C; O2 sat <90%
5.Activity: Bedrest with bedside commode
6.Nursing: Pulse oximeter, guaiac stools, O2 at 2 L by NC.
Antiembolism stockings. No intramuscular injections.
7. Diet: Regular
8. IV Fluids: D5W at TKO.
9. Special Medications:
Anticoagulation:
-Heparin IV bolus 5000-10,000 Units (100 U/kg) IVP,then 1000-1500 U/h
IV infusion (20 U/kg/h) [25,000U in 500 mL D5W (50 U/mL)]. Check PTT
6 hours after initial bolus; adjust q6h until PTT 1.5-2 times control (60-80 sec).
Overlap heparin and Coumadin for at least 4 days and discontinue heparin when
INR has been 2.0-3.0 for two consecutive days.
-Enoxaparin (Lovenox) 1 mg/kg sq q12h for 5 days for uncomplicated pulmonary
embolism. Overlap warfarin as outlined above.
-Warfarin (Coumadin) 5-10 mg PO qd for 2-3 d, then 2-5 mg PO qd.
Maintain INR of 2.0-3.0. Coumadin is initiated on second day if the PTT is
1.5-2.0 times control. Check INR at initiation of warfarin and qd
[tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].
Thrombolytics (indicated if hemodynamic compromise):
Baseline Labs: CBC, INR/PTT, fibrinogen q6h.
Alteplase (recombinant tissue plasminogen activator,Activase): 100 mg IV infusion
over 2 hours, followed by heparin infusion at 15 U/kg/h to maintain
PTT 1.5-2.5 x control OR
Streptokinase (Streptase): Pretreat with methylprednisolone 250 mg IV push and
diphenhydramine (Benadryl) 50 mg IV push. Then give streptokinase, 250,000 units
IV over 30 min, then 100,000 units/h for 24-72 hours. Initiate heparin
infusion at 10 U/kg/hour; maintain PTT 1.5-2.5 x control.
10. Symptomatic Medications:
-Meperidine (Demerol) 25-100 mg IV prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
11. Extras: CXR PA and LAT, ECG, VQ scan; chest CT scan, pulmonary
angiography; Doppler scan of lower extremities, impedance cardiography.
12. Labs: CBC, INR/PTT, SMA7, ABG, cardiac enzymes.Protein C, protein S,
antithrombin III, anticardiolipin antibody. UA . PTT 6 hours after bolus and q4-6h.
INR at initiation of warfarin and qd.
