Pulmonary embolism

Background

• Suspect in pt w/ dyspnea, tachypnea, or pleuritic pain
• Only 40% of ambulatory ED pts w/ PE have concomitant DVT

Diagnosis

• Wells Score

1. Symptoms of DVT - 3pts
2. No alternative diagnosis better explains the illness - 3pts
3. HR > 100 - 1.5 pts
4. Immobilization within prior 4wks - 1.5pts
5. Prior history of DVT or PE - 1.5pts
6. Active malignancy - 1pt
7. Hemoptysis - 1pt

• Wells Criteria:

1. 0-1 point: Low probability (3.4%)
2. 2-6 points: Moderate probability (27.8%)
3. 7-12 points: High probability (78.4%)

Low Probability

• If low prob and PERC Rule neg then d/c
• If low prob and PERC Rule pos then d-dimer

Moderate Probability

• Obtain d-dimer

High Probability

• Consider anticoagulation before imaging!
• CTPA if GFR >60
• V/Q if GFR <60

TREATMENT

Anticoagulation

• • Indicated for all patients with confirmed PE or high clinical suspicion
  • Treatment options:
    • LMWH SC
      • 1st line for most hemodynamically stable pts
    • UFH
      • Consider in pts w/:
        • Persistent hypotension
        • Increased risk of bleeding
        • Recent sx/trauma
        • Renal failure (GFR <30)
        • Morbid obesity or anasarca (poor sc absorption)
        • Thrombolysis is being considered

Thrombolysis

• Associated with ICH in 3% of pts
• Consider for patients with confirmed PE and shock
  • Can also consider, although controversial, for:
    • Severe hypoxemia (SpO2<90% despite O2)
    • Massive embolic burden on CT
    • RV dysfunction
    • Free-floating RA or RV thrombus
    • Patent foramen ovale
  • Absolute contraindications:
    • History of hemorrhagic stroke
    • Active intracranial neoplasm
    • Recent (<2 months) intracranial sx or trauma
    • Active or recent internal bleeding in prior 6 months
  • Relative contraindications:
    • Bleeding diathesis
    • Uncontrolled severe HTN (sys BP >200 or dia BP >110)
    • Nonhemorrhagic stroke within prior 2 months
    • Surgery within the previous 10 days
    • Plt < 100K

Source

Tintinalli

UpToDate