Pulmonary Embolism

Author: Steven D Crane, Jason B Lee, Francis P Morris / Editor: Jason M Kendall, Emer Kidney / Reviewer: Eugene Henry / Codes: A2 / Published: 18/05/2023

The module covers assessment and management of the patient presenting in the Emergency Department (ED) with a pulmonary embolism (PE).

After completing this session you will be able to:

  • Reflect on the importance of considering the diagnosis of PE in a variety of presentations.
  • Describe the different risk stratification tools available for patients presenting to the ED with possible PE.
  • Describe both the limitations of D-Dimer testing and the difference between quantitively and qualitative tests.
  • Formulate an appropriate management plan for the patient with suspected PE.
  • Initiate time critical therapy for a patient with a suspected massive PE.

References

  1. Francis CW. Clinical Practice. Prophylaxis for thromboembolism in hospitalised medical patients. New England Journal of Medicine. 2007; 356(14): p. 1438-1444.
  2. Officer DoHaCM. Report of the independent expert working group on the prevention of venous thromboemolism in hospitalised patients. Guideline Ref ID DH2007.
  3. Ferrari E, Baudouy M, Cerboni P, Tibi T, Guigner A, Leonetti J, Clinical epidemiology of venous thromboembolic disease. Results of a French Multicentre Registry. Eur Heart J. 1997 Apr;18(4):685-91.
  4. Janata K, Holzer M, Domanovitis H, Mullner M, Bankier A, et al. Mortality of patients with pulmonar embolism. Wein Klin Wochenschr. 2002 Sep; 30(114).
  5. Wells PS, Anderson DR, Rodger M, Stiell , et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using simple clinical model and d-dimer. Annals of Internal Medicine. 2001; 135.
  6. Morrone D, Morrone V. Acute Pulmonary Embolism: Focum on the Clinical Picture. Korean Circulation Journal. 2018 May; 48(5).
  7. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax. 2003; 58: p. 470-483.
  8. Pruszczyk P, Szulc M, Torbicki A. Troponin levels in acute pulmonary embolism. Chest. 2002; 122: p. 2264-2265.
  9. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Annals of Internal Medicine. 2006; 1444(3): p. 165-171.
  10. Klok FA, Mos , ICM , Nijkeuter M, et al. Simplification of the Revised Genev Score for Assessing Clinical Probability of Pulmonary Embolism. Arch Intern Med. 2008; 168(19): p. 2131-2136.
  11. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicentre evaluation of the pulmonary embolism rule-out criteria. Journal of Thrombosis and Haemostasis. 2008; 6(5).
  12. Singh B, Parsaik AK, Agarwal D, et al. Diagnostic Accuracy of the Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-Analysis. Annals of Emergnecy Medicine. 2012; 59(6): p. 517-520.
  13. Acute Venous Thromboembolic Disease. American College of Emergency Physicians clinical policies subcommittee. [Online]. 2018.
  14. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE guideline [NG158]. 2020.
  15. Sadosty AT, et al. Emergency department D-dimer testing. Journal of Emergency Medicine. 2001; 21(4): p. 423-429.
  16. Ginsberg JS, Wells PS, Kearon C, et al. Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. Annals of Internal Medicine. 1998; 129(12): p. 1006-11.
  17. Kearon C, Ginsberg JS, Douketis H, et al. (CANPEDS Group). An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomised trial. Annals of Internal Medicine. 2006; 144(11): p. 812-21.
  18. Goodman LR, Lipchik RJ, Kuzo RS, et al. Susequent pulmonary embolism risk after a negative helical CT pulmonary angiogram: prospective comparison with scintigraphy. Radiology. 2000; 215.
  19. Nilsson T, Olausson A, Johnsson H, et al. Negative spiral CT in acute pulmonary embolism. Acta Radiology. 2002; 43.
  20. Hritani R, Alrifai A, Soud M, Pacha HM, Alraies MC. Which patients with pulmonary embolism need echocardiography. Cleveland Clinic Journal of Medicine. 2018 Nov; 85(11): p. 826-828.
  21. Daniel KR, Jackson RE, Kline JA. Utility of lower extremity venous ultrasound scanning in the diagnosis and exclusion of pulmonary embolism in outpatients. Annals of Emergency Medicine. 2000; 35.
  22. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jimnez D, Kucher N, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603.
  23. PEITHO Investigators. Fibrinolysis for patients with Intermediate-Risk Pulmonary Embolism. New England Journal of Medicine. 2014;(340): p. 1402-1411.
  24. HI-PEITHO Investigators. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for intermediate-high-risk Pulmonary Embolism: Rational and design of the HI-PEITHO study. American Heart Journal. 2022 September; 251: p. 45-53.
  25. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. American Journal of Respiratory Critical Care Medicine. 2005; 172(8): p. 1041-1046.
  26. Jimenez D, Aujesky D, Moores L, et al. Simplification of the Pulmonary Embolism Severity Index for Prognostication in Patients with Acute Symptomatic Pulmonary Embolism. Archives of Internal Medicine. 2010; 170(15): p. 1383-1389.
  27. Lee AY, Levine MN, Baker RI, et al. Low-molecular weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patient with cancer. New England Journal of Medicine. 2003; 349(2): p. 146-153.
  28. McColl MD, Tait RO, Greer IA, et al. Injecting drug use is a risk factor for deep vein thrombosis in women in Glasgow. British Journal of Haematology. 2001; 112(641).

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