who’s in shock is suffering from a massive pulmonary embolism? Table 1, p. 36, lists common clinical features suggesting the presence
of massive pulmonary embolism.
A simple scoring system has been developed
to aid practitioners in estimating the likelihood that a patient’s acute symptoms might be
due to a pulmonary embolism. 1 (See Table 2.)
In addition, a field electrocardiogram may
provide additional clues, such as sinus tachycardia, an incomplete right bundle branch
block, inverted T-waves in V1–V3, and/or
the infrequent S1Q3T3 pattern (an S-wave
in Lead 1, Q-wave in Lead 3, and an inverted
T-wave in Lead 3). 2 (See Figure 1, p. 36.)
Other important elements of our EMS system now include regional EMS protocols for
identification and triage of patients to an ED/
ECMO-capable receiving hospital.
Our current selection guidelines for ED
ECMO, which include selected witnessed
out-of-hospital cardiac arrest patients, as well
as those with suspected massive pulmonary
embolism, are shown in Table 3.
At VCU, we have a well-established Pulmonary Embolism Response Team (PERT),
as well as an ECMO alert team capable of
assembling a multidisciplinary specialty team
at the patient’s bedside in the ED or in hospital 24/7 within minutes.
Over the last five years, we’ve placed more
than 500 patients on emergency ECMO
(approximately 2–3 in the ED per month).
Our options for clot removal have broadened,
with fewer patients requiring surgical embolectomy and more patients being treated using
pharmacologic and interventional radiology
clot removal procedures.
Many hospitals in the United States are currently
capable of placing patients on ECMO, particu-
larly on a semi-emergent basis in the operating
room, cardiac catheterization laboratory or the
ICU. However, very few hospitals have organized
the capability to place patients on ECMO rap-
idly in the ED, particularly in the “off hours.”
In addition to specialized portable equip-
ment and in-house perfusionists, a hospital
needs to provide this level of care frequently
to maintain proficiency. For massive pulmo-
nary embolism and qualifying cardiac arrest
patients, the odds of surviving neurologically
intact decrease rapidly from the time of arrest
until ECMO perfusion is in place.
So, as in many things in emergency care,
time is the enemy and an effective system must
consistently win the race against time. JEMS
Joseph P. Ornato, MD, FACP, FACC, FACEP, is professor and
chairman of the Department of Emergency Medicine at the
Virginia Commonwealth University Health System. He’s also
the operational medical director for the Richmond (Va.)
Ambulance Authority, Richmond Fire and EMS, and Henrico
County Division of Fire.
1. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple
clinical model to categorize patients probability of pulmonary
embolism: increasing the models utility with the SimpliRED
D-dimer. Thromb Haemost. 2000;83( 3):416–420.
2. Qaddoura A, Digby GC, Kabali C, et al. The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and
meta-analysis. Clin Cardiol. June 19, 2017. [Epub ahead of print.]
Table 2: Wells’ score for estimating the probability that a patient’s
acute symptoms might be caused by a pulmonary embolism1
Suspected deep vein thrombosis (DV T) 3.0
An alternative diagnosis is less likely than pulmonary embolism (PE) 3.0
Heart rate > 100 bpm 1. 5
Immobilization or surgery in the previous four weeks 1. 5
Previous DV T or PE 1. 5
Malignancy (on treatment, treated in the last six months, or palliative) 1.0
0– 1 40 4% Low
2–6 53 21% Moderate
> 6 7 67% High
Table 3: Current VCU ED ECMO treatment guidelines
✓ Age < 70 ✘ Unwitnessed arrest
✓ Suspected massive pulmonary embolism
• Follows commands ✘ Initial rhythm Is not v fib
✓ Cardiac arrest
• Witnessed, initial rhythm is v fib
• No sustained ROSC after 20 mins. ALS in the field
• Transport time to VCU < 20 mins.
• Potentially correctable cause (PE, refractory v tach/v fib)
✘ Known symptomatic chronic
organ failure, advanced
illness, do not attempt
resuscitation order, etc.
✘ > 10 mins. without CPR