Ambulatory Pulmonary Embolism (PE) Pathway

What is the Ambulatory PE Pathway?

The team treating you believe that your symptoms may be being caused by a pulmonary embolism and have given you some anticoagulant medication to start treating this.

The team feel you are suitable for outpatient management and have arranged your follow-up in the Acute Medical Clinic (AMC). This is for further tests, to help confirm your diagnosis.

How does this pathway work?

You will receive a phone-call within five days to arrange your appointment.

If you have not heard from AMC about your appointment in five days, please contact the Emergency Assessment Unit at North Tees on 01642 383293 (seven days a week, 8:00 am to 8:00 pm).

At your appointment:

• You will be seen by a member of the AMC team, have your observations checked and have a cannula (a thin, flexible tube to deliver medicines or fluids) placed.
• You will be taken for a scan of your lungs that uses contrast (a dye) to help us get the best pictures.
• Following the scan, you will return to clinic, where you will be reassessed by a clinician and your results will be reviewed.

Before you are discharged, the team in AMC will discuss the next steps, and give you further medication if appropriate.

What should I do if I run out of medication?

You should take the medication you have been given, as prescribed, until your appointment, unless told otherwise by a medical professional.

You have been given a one-week supply of medication. Your appointment should be completed within this week. If needed, the AMC team will arrange further medication at your appointment.

What should I do if I feel unwell / worse?

If your symptoms worsen, you should seek immediate medical attention / return to hospital (Emergency Department) for reassessment.

What is a pulmonary embolism?

A pulmonary embolism (PE) is a blood clot on the lung.

How does this happen?

Most commonly, people develop blood clots in the veins of the legs or the abdomen. This is known as deep vein thrombosis (DVT). These clots can break off and travel up the veins to your heart and then from your heart to your lungs, where they become lodged.

What symptoms would I have had due to my pulmonary embolism?

The most common symptom of a pulmonary embolism is breathlessness. Other symptoms can be chest pain (which is worse on breathing or coughing), cough, fever and coughing up blood.  It may also make your heart beat very fast or irregularly and give you a feeling of palpitations.

A larger pulmonary embolism may make you feel light headed or can cause you to faint or lose consciousness.

How will my pulmonary embolism be diagnosed?

You will undergo a lung scan. The most common lung scan to be used is an X-ray test called a CT scan. The particular type of CT scan is called a pulmonary angiogram.

This involves injecting dye into a drip in your arm or hand which then travels to your heart and is pumped through your lungs. This dye helps to show which blood vessels within the lung the blood clots are in.

If you are pregnant or have other reasons for you not to have a CT scan, you may undergo a slightly different type of lung scan. This is also a type of X-ray scan called a ventilation / perfusion scan (VQ scan). The medical team will have picked the most appropriate test for you.

You may also have had a number of other tests as part of your initial investigations. These will have included a chest X-ray, blood tests and heart tracing (also known as an ECG). These tests would have helped to diagnose a possible blood clot. They would have also given the team an understanding of how much stress or strain the blood clot was placing on your body.

What treatment am I having?

The most common treatment for blood clots in the lungs is blood thinning drugs. There are a number of different drugs that can be used. These include tablets (Warfarin, Rivaroxaban, Apixaban) and injections (Tinzaparin, Enoxaparin).

The purpose of these medicines is to thin your blood to cut down your risk of having another blood clot. The treatment does not actually dissolve the blood clot itself. The body removes the blood clot over the course of several weeks with the same process that it uses to heal bruises.

How long will I need treatment for?

The length of time that a patient requires treatment with blood thinning drugs can vary from just 3 months to being required for the rest of the patient’s life.

The duration of treatment will depend on a number of different factors including:

•         What may have caused the blood clot to form.

•         How unwell you were.

•         How likely you are to have another blood clot in the future.

The team looking after you take this all into consideration before they make a recommendation on how long they would wish you to stay on treatment.

It may be that following your appointment, you no longer need to take any anticoagulant medication.

How will I feel when I am recovering from my pulmonary embolism?

The most common symptoms are breathlessness and fatigue. These get better gradually but can take several weeks to months for you to return to normal. The best aid to recovery is to live as normal a life as possible and to exercise to gradually build up your fitness.

Anticoagulation

Whilst you are awaiting testing for your suspected pulmonary embolism, your doctor has recommended that you start taking a medicine known as an anticoagulant or “blood thinner”.

What are anticoagulants?

Anticoagulants are drugs used to reduce your body’s ability to form blood clots.

Are there different types of anticoagulants?

The most commonly used anticoagulants at North Tees and Hartlepool NHS Foundation Trust are:

• Apixaban (brand name Eliquis®). This is a tablet usually taken orally once or twice a day.
• Tinzaparin. A low-molecular weight heparin (LMWH), which is given using a small injection into the fat below the skin, often in the tummy. This may be given once or twice a day. This is the most common medicine given to people while in hospital to try to prevent blood clots forming.

What dose of anticoagulant will I take?

The exact dose of anticoagulant, and how often it should be taken may vary from person to person and you should follow the specific instructions given to you by your doctor.

Your anticoagulant should be taken around the same time each day. It is a good idea to set an alarm if you think you may struggle to remember.

For how long will I need to take this medicine?

You should take this medication until your appointment in the Acute Medical Clinic. You will be told after your scan, and review in the Acute Medical Clinic whether this will need to continue, be changed or can be stopped.

Depending on the reason that you are taking an anticoagulant, you may only need it for a short time (such as a few weeks or months), or it may be required lifelong. This will be discussed with you by the doctor prescribing the medication.

Will I still be given an anticoagulant if I am already taking medicine to thin my blood?

You may already be taking medicines, such as aspirin, clopidogrel, dipyridamole or ticagrelor. These medicines do thin your blood, but in a different way to anticoagulants. You may still be asked to continue these medicines while taking an anticoagulant, depending on the reason these other medicines have been prescribed.

These medicines can be taken at the same time as an anticoagulant, but can increase the risk of bleeding (see the section below on bleeding and side effects) and this risk will be considered by your doctor before starting an anticoagulant.

Are there any reasons why I should not be given an anticoagulant?

Some people may not be suitable to take an anticoagulant, or they may need a different dose than would normally be prescribed.

It may not be suitable to take anticoagulants if you:

• Have chronic kidney or liver disease.
• Have stomach or bowel ulcers or fragile veins in your stomach or oesophagus (gullet).
• Have problems in your arteries and veins such as aneurysms or arteriovenous malformations (unusual connections between arteries and veins).
• Have high blood pressure which has not responded to treatment.
• Have conditions that cause them to bleed easily (such as haemophilia).
• Are pregnant (see pregnancy section).
• Have already been given medicine that increases the risk of bleeding.
• Have a condition called antiphospholipid syndrome.

You should also tell your doctor if you:

• Have recently or previously had a stroke.
• Have had surgery or a procedure (especially on the brain, spine or eyes).
• Have had a large bleed (such as following giving birth or from the stomach).
• Are planning to have surgery or a procedure in the future.

The benefits and risks of starting an anticoagulant should be considered by you and your doctor together before you start taking it.

Different anticoagulants may be more suitable if you have any of the health conditions mentioned, and so it may still be possible to start taking an alternative anticoagulant.

Am I at an increased risk of bleeding when taking an anticoagulant?

All anticoagulant medicine will increase your risk of bleeding as it affects your body’s ability to make blood clots. This is the most important and potentially severe side effect.

It is common to experience minor bleeding such as:

• Small cuts bleeding for longer than usual. In this case, apply firm pressure for 5 to 10 minutes continuously.
• Bleeding from gums while brushing teeth.
• Bruising easily.
• Heavier periods than normal for women.
• Nosebleeds (lasting less than 10 minutes). In this case, pinch your nose just above the nostrils for 10 to 15 minutes continuously and lean forward.

In these cases, bleeding should stop by itself and you should continue to take your anticoagulant. If bleeding becomes regular and continuous, you should seek medical attention.

Rarely, more serious bleeding can occur. Signs of serious bleeding include:

• Blood coming up when you vomit or cough.
• Blood coming from your anus (back passage).
• Visible blood or redness to your urine.
• A change in your stools (poo). They may become black, smelly, loose and tar-like (called “melena”).
• Severe headaches, change in your vision or seizures (fits).
• Severe abdominal (stomach) pain.
• Significant bruising without a history of injury (spontaneous) or bruising that spreads.
• Prolonged bleeding, such as a nosebleed over 10 minutes or a cut where you cannot slow down the bleeding with firm pressure and advice above.

What should I do if I notice any bleeding?

If you experience any of the serious symptoms above, you should immediately contact your usual doctor, or go to Accident and Emergency out-of-hours if you feel unwell.

These symptoms may indicate a serious or even life-threatening bleed and may need urgent investigation or treatment.

You should also call 999 or attend Accident and Emergency if you are involved in a traumatic injury (such as a car crash or a fall down the stairs) or if you experience a head injury.

This is because taking anticoagulation increases your risk of internal bleeding or bleeding within the brain. This may not be obvious and you should be seen urgently by a medical professional.

In cases of serious bleeding above, there are medications available to reverse or counteract the effects of your anticoagulation that will be considered by the medical team.

If you are unsure what to do, call the NHS helpline on 111 at any time of day to discuss your concerns.

What should I do if I am having a procedure or surgery?

If you are having a procedure, operation or dental work, the team that is planning the procedure will need to know you are under investigation for a blood clot, and now taking an anticoagulant.

You will normally be asked about your medication before having any procedure, however if you are not asked, please make sure you tell the team. This will allow them to plan the best way to stop your anticoagulant before the procedure.

Can I stop taking my anticoagulant?

If you stop suddenly without support from a medical professional, you may suffer serious and even life-threatening consequences.

If you are experiencing significant bleeding as described above, do not take any further doses of your anticoagulant and seek urgent medical attention as mentioned.

Can anticoagulants affect any of my other medicines?

Yes. Some anticoagulants can interact with other medicines.

These can include antibiotics, epilepsy medication, non-steroidal anti-inflammatory medication (such as ibuprofen) and other medications that increase the risk of bleeding or the way the body interacts with your anticoagulant.

If a doctor or practitioner is planning to start you on a new medicine, you should tell them you are taking anticoagulants so that they can make sure they are safe to take together.

You should also be very careful with any medicine that you buy over the counter such as aspirin, ibuprofen, paracetamol, vitamins, supplements and herbal remedies (especially St John’s Wort).

This medication can interact with anticoagulants and/or increase your risk of bleeding from your stomach. Discuss these medications with your pharmacist or your general practitioner before starting them. You must always follow the information leaflet provided with any new medication before taking it if you are unsure.

What monitoring is required when taking an anticoagulant?

If Tinzaparin or Apixaban is only taken for short periods, you will not need routine monitoring. A blood test to check your kidney function and haemoglobin levels should be checked before you start taking this medicine.

These levels may be checked routinely if you need anticoagulants for long periods, to ensure that they are safe to take at your current dose.

Is there anything I should know about taking Tinzaparin?

Tinzaparin is given as an injection into the area just below the skin (the subcutaneous fat). The needles used are small and are usually painless. Administering tinzaparin is simple and can usually be carried out by the patient themselves, their carer or a District Nurse. If you wish, your doctor or nurse can train you or a carer to administer tinzaparin to yourself. Each time a needle is used to administer tinzaparin, the needle must be discarded safely using a yellow “sharps bin”. This should be provided by the hospital or your Community Health Trust and disposed of safely by your local surgery or pharmacist once full. Do not throw needles or a sharps bin in normal domestic waste.

What if I am pregnant or breastfeeding?

Some anticoagulants (such as apixaban) are not suitable for pregnant women as there is limited information on their safety.

Low molecular weight heparins, such as tinzaparin, are generally considered more suitable during pregnancy and are recommended by national bodies.

Your doctor may consider using these, or a different anticoagulant such as heparin, following discussion with a specialist if an anticoagulant is needed while you are pregnant or breastfeeding.

What if I miss a dose or take too much?

It is important to try to take your medication at the same time each day, to reduce the risk of side effects and to make your anticoagulant as effective as possible.

If you forget to take your anticoagulant, you should take it as soon as you remember, unless it is nearly time for your next dose. If this is the case, take your next dose of anticoagulant as normal.

If you do forget your medication, never double your next dose. You should only take the dose that has been recommended.

If you accidentally take a larger dose of your anticoagulant than you are meant to, you should seek urgent medical assistance from your general practitioner or phone 111 out of hours, as you are at an increased risk of bleeding.

Is it safe to drink alcohol while taking an anticoagulant?

It is generally safe to consume small amounts of alcohol within the government recommended limits while taking an anticoagulant. Despite this, the safest option is to avoid alcohol as much as you can while using blood anticoagulants.

If you are pregnant or there is a chance you might be pregnant, it is advised that you avoid alcohol.

Regular consumption of more than the recommended limits or excessive binges can affect the way your liver interacts with medications.

This can make them less effective or make them more potent and the side effects (such as bleeding) more likely.

Drinking alcohol over the recommended limit also increases your risk of developing an ulcer or bleeding in your stomach. Excessive alcohol may also lead to falls and head injuries.

If you are taking an anticoagulant, this bleeding may be more serious, and so it is important to avoid exceeding the safe alcohol limit.

Is it safe to fly while taking an anticoagulant?

These medications are safe to take while flying.

Long flights can increase your risk of developing clots in the vein. If you are taking anticoagulants because you are at risk of developing clots, you should discuss whether it is safe to fly with your doctor before planning a flight.

Your doctor will tell you what other measures can be taken to reduce your risk (such as wearing compression stockings).

If you are taking an anticoagulant because of a clot on the lung (pulmonary embolism), then your lungs may struggle to get enough oxygen into your body. It may not be safe to fly and you should ask your doctor before planning a flight.

If you are going on holiday, make sure you take enough medication and have appropriate insurance for your medical needs.

What should I do if I suffer a head injury?

If you suffer any form of head injury while using anticoagulants, you should seek medical advice immediately. This is because any bleeding is much more serious while using this medication.

Contact numbers

If you need further advice, or have any problems, please contact the number below:

North Tees & Hartlepool NHS Foundation Trust

Emergency Assessment Unit

Telephone: 01642 383293

Monday to Sunday, 8:00 am to 8:00 pm

Patient Experience Team (PET)

North Tees and Hartlepool NHS Foundation Trust would like your feedback. If you would like to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Team who will help you to do this.

This service is based at the University Hospital of North Tees but also covers The University Hospital of Hartlepool, our community hospitals and community health services.

North Tees and Hartlepool NHS Foundation Trust
Telephone: 01642 624719
Freephone: 0800 092 0084
Email: [email protected]
Monday to Friday, 9:30 am to 4:00 pm

Out of Hours
If you wish to speak to a senior member of Trust staff, please contact the hospital switchboard (numbers below).