PE, tamponade and aortic emergencies

Obstructive and aortic emergencies: PE risk stratification (ESC 2019 and the new AHA/ACC 2026 categories) and thrombolysis, acute RV failure, tamponade and pericardiocentesis, aortic dissection impulse control, and ruptured AAA.

5 topics

01
PE risk stratification and thrombolysis
Stratify acute PE by haemodynamics, sPESI, RV dysfunction and troponin (ESC 2019 and AHA/ACC 2026 categories), and choose anticoagulation, thrombolysis or advanced therapy.
7 stepsAlgorithm5 dosesNew
02
Acute right ventricular failure
Recognise and support the failing RV: optimise preload, maintain systemic pressure, reduce afterload and add inotropes, and ventilate safely.
7 stepsAlgorithm2 dosesNew
03
Cardiac tamponade and pericardiocentesis
Clinical and echo diagnosis of tamponade, temporising measures, and urgent drainage.
6 stepsAlgorithmNew
04
Acute aortic dissection: BP and HR targets
Recognise acute aortic syndrome, start impulse control (HR < 60, SBP < 120) with beta-blocker first, and route type A to surgery.
7 stepsAlgorithm4 dosesNew
05
Ruptured abdominal aortic aneurysm
Rapid recognition, permissive hypotension, massive transfusion and immediate transfer for EVAR or open repair.
6 stepsAlgorithm1 dosesNew

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Alteplase (rt-PA)

Fibrinolytic

Indications: High-risk (category E) PE; rescue in deteriorating intermediate-high-risk PE
Adult dose: 100 mg IV over 2 h (10 mg bolus + 90 mg over 2 h). Cardiac arrest due to PE: 0.6 mg/kg (max 50 mg) over 15 min; continue CPR 60-90 min.
Preparation (India): 50 mg vials (expensive in India).
Cautions: Stop UFH during infusion; restart when aPTT < 2x normal. Absolute contraindications: prior haemorrhagic stroke, ischaemic stroke < 6 months, CNS neoplasm, major trauma/surgery/head injury < 3 weeks, active bleeding, bleeding diathesis.

Tenecteplase

Fibrinolytic

Indications: High-risk PE (off-label alternative where alteplase not available)
Adult dose: Weight-based single IV bolus: < 60 kg 30 mg; 60-69 kg 35 mg; 70-79 kg 40 mg; 80-89 kg 45 mg; ≥ 90 kg 50 mg.
Preparation (India): 20 mg and 40 mg vials (Indian brands) - check vial size; reconstitute 5 mg/mL.
Cautions: PEITHO (full-dose TNK in intermediate-risk) showed more haemorrhagic strokes (2% vs 0.2%).

Streptokinase

Fibrinolytic

Indications: High-risk PE where alteplase/TNK unavailable
Adult dose: Accelerated: 1.5 million IU IV over 2 h. Older regimen: 250,000 units over 30 min then 100,000 units/h for 12-24 h.
Preparation (India): 15 lakh (1.5 million) IU vials widely available and cheap in India.
Cautions: Hypotension, allergy; do not repeat within 6-12 months (antibodies).

Unfractionated heparin

Anticoagulant

Indications: PE when thrombolysis/procedure possible, haemodynamic instability, severe renal impairment (CrCl < 30 mL/min)
Adult dose: 80 units/kg IV bolus, then 18 units/kg/h; adjust to aPTT 1.5-2.5x control (or anti-Xa 0.3-0.7 units/mL).
Preparation (India): 5,000 units/mL vials; 25,000 units in 50 mL NS = 500 units/mL.
Monitoring: aPTT 6 h after start and after each change; platelets (HIT).

Enoxaparin (LMWH)

Anticoagulant

Indications: PE without haemodynamic instability (preferred parenteral agent)
Adult dose: 1 mg/kg SC every 12 h (or 1.5 mg/kg daily). CrCl 15-30 mL/min: 1 mg/kg once daily.
Preparation (India): 40, 60, 80 mg prefilled syringes.
Renal / hepatic: Avoid or anti-Xa monitor if CrCl < 15 mL/min; use UFH.

Noradrenaline

Vasopressor

Indications: Hypotension in RV failure, PE, tamponade bridge
Adult dose: 0.05-0.5 mcg/kg/min, titrate to MAP ≥ 65 mmHg (higher may be needed to perfuse the RV).
Preparation (India): 4 mg in 50 mL = 80 mcg/mL (or 8 mg in 50 mL = 160 mcg/mL); central line preferred, peripheral short-term acceptable.

Dobutamine

Inotrope

Indications: Low cardiac output in RV failure
Adult dose: 2.5-10 mcg/kg/min.
Preparation (India): 250 mg in 50 mL = 5,000 mcg/mL.
Cautions: Tachyarrhythmias, hypotension (combine with noradrenaline).

Esmolol

Short-acting beta-1 blocker

Indications: Aortic dissection HR control (first line)
Adult dose: Loading 500 mcg/kg over 1 min, then 50-300 mcg/kg/min infusion; titrate to HR < 60/min.
Preparation (India): 100 mg/10 mL vials; often run undiluted 10 mg/mL.
Cautions: Bradycardia, bronchospasm (less than non-selective), avoid in cocaine-related dissection and acute AR with shock.

Labetalol

Alpha + beta blocker

Indications: Aortic dissection HR and BP control
Adult dose: 20 mg IV over 2 min, then 20-80 mg every 10 min (max 300 mg) or infusion 0.5-2 mg/min.
Preparation (India): 20 mg/4 mL (5 mg/mL) ampoules; infusion 200 mg in 200 mL = 1 mg/mL.
Cautions: Asthma, heart block, decompensated heart failure.

Glyceryl trinitrate (nitroglycerin)

Vasodilator

Indications: Additional BP control in dissection after beta-blockade
Adult dose: Start 5-10 mcg/min, increase by 5-10 mcg/min every 3-5 min (usual up to 200 mcg/min).
Preparation (India): 25 mg/5 mL ampoules; 50 mg in 50 mL = 1,000 mcg/mL (6 mL/h = 100 mcg/min).
Cautions: Reflex tachycardia if given before beta-blocker; headache; tolerance.

Morphine / fentanyl

Opioid analgesic

Indications: Pain in aortic dissection (reduces sympathetic drive)
Adult dose: Morphine 2-4 mg IV titrated every 5-10 min; or fentanyl 25-50 mcg IV.
Preparation (India): Morphine 10 mg/mL ampoules; fentanyl 50 mcg/mL.

Packed red blood cells (PRBC) with plasma and platelets

Blood component

Indications: Haemorrhagic shock (ruptured AAA)
Adult dose: Massive transfusion: PRBC:FFP:platelets 1:1:1 until bleeding controlled.
Preparation (India): ~250-350 mL per unit; O-negative/O-positive uncrossmatched in emergency.
Cautions: Warm products; monitor ionised calcium, potassium and temperature.

5 topics

PE risk stratification and thrombolysis

Acute right ventricular failure

Cardiac tamponade and pericardiocentesis

Acute aortic dissection: BP and HR targets

Ruptured abdominal aortic aneurysm

Drugs in this module

Module references (10)