PE

Pulmonary Embolism

SSX:

  • Tachycardia (MC)

  • Hypoxia despite supplemental O's

  • Dyspnea/orthopnea/tachypnea

  • Pleuritic chest pain

  • Cough/hemoptysis/wheezing

  • Calf/thigh pain/swelling

  • ± Fever

  • Massive PE can ➔ right HF ➔ JVD and/or S3

  • EKG may show right heart strain

    • T-wave inversions in right heart precordial leads (V1-4) ± S1 Q3 T3

  • CXR may show Hampton hump: wedge shaped infiltrate (pulmonary infarct)

DX: Wells' criteria (for PE)

  • High risk of PE - Wells' (PE) >6

    • CT pulmonary angiogram (and start tPA)

  • Intermediate risk of PE - Wells' (PE) 2-6

    • D-dimer > 500ng/mL ➔ CT pulmonary angiogram

  • Low risk of PE:

    • Does pt have any PERCs (PE Rule-out Criteria)?

      • **ONLY FOR LOW RISK PTS**

    • HX - HOT - HOSE

      • HX DVT/PE

      • Hypoxia (O2 sat < 95%)

      • Older than 50yo

      • Tach (HR > 100)

      • Hemoptysis

      • One sided leg swelling

      • Surgery/trauma/hospitalization in last 4 weeks

      • Estrogen

        • If pt has none of the PERCs ➔ no further testing needed

        • If pt has any of PERCs➔ D-dimer

          • D-dimer > 500ng/mL ➔ CT pulmonary angiogram

  • V/Q scan if CTPA is CI (hx of contrast allergy, GFR <30, hypotensive, advanced HF)

Wells' score (PE)

  • 3 Points each:

    • SSX of DVT

    • PE is likely

  • 1.5 Points each:

    • Heart rate > 100

    • Immobilization (3d) surgery (4wks)

  • HX DVT/PE

  • 1 Point each:

    • Hemoptysis

    • Malignancy (tx'd within last 6mo or palliative)

TX:

  • Heparin/LMWH or NOACs

  • AND 3mo of continued anticoagulation

    • IVC filter if anticoagulation CI or ↑ bleeding risk

  • UNSTABLE pts get systemic thrombolysis via tPA