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0823 Pulmonary Embolism Emergency Medicine
0823 Pulmonary Embolism Emergency Medicine
CLINICAL CHALLENGES:
• What are the clinical risk factors
for pulmonary embolism?
• How are patients assessed
for probability of pulmonary
embolism?
• What are the highest-value
diagnostic tests for detecting a
pulmonary embolism?
Authors
Alfred Sacchetti, MD, FACEP
Director of Clinical Services, Emergency
Department, Virtua Our Lady of Lourdes
Hospital, Camden, NJ; Assistant Clinical
Professor of Emergency Medicine, Thomas
Jefferson University, Philadelphia, PA
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• His ECG is normal sinus rhythm at 95 beats/min and his resting pulse oximetry is at 94%. There are no
other abnormalities. Chest x-ray, natriuretic peptide, and high-sensitivity troponin are normal.
• All of his symptoms can be explained by his weight, but you wonder whether you should start down a
diagnostic pulmonary embolism algorithm...
A 65-year-old woman presents with a complaint of shortness of breath she developed that morning…
• She says she recently recovered from COVID-19 disease and was doing well prior.
CASE 2
• On examination, her lungs have a few residual ronchi from her illness, but are otherwise clear. Vital signs
are normal, and her pulse oximetry is 97% on room air. As part of her workup, a D-dimer is ordered and
returns incalculably high. She has a well-documented IV contrast allergy. A pulmonary perfusion scan
was ordered, which shows a clear perfusion defect consistent with a pulmonary embolism.
• You consider whether this patient is a candidate for outpatient treatment and which medications to use...
prior. She said she developed severe shortness of breath about 1 hour ago when she stood up from a
recliner she had been resting in.
• On arrival to the ED, she was cyanotic, tachypneic, tachycardic, and verbalizing “I can’t breathe”
repeatedly. Initial pulse oximetry was 70%, with a sinus tachycardia of 130 beats/min and a blood
pressure of 84/40 mm Hg.
• Does this patient require endotracheal intubation, and should thrombolytics be started immediately?
Cancer 1 2
Previously diagnosed PE or DVT 1.5 3 1
Hormonal estrogenic treatment 1
Hemoptysis 1 2 1 1
Clinical signs of DVT 3 1
Unilateral lower limb pain 3
Pain on lower limb deep vein palpation and unilateral edema 4 1
Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism; PERC, pulmonary embolism rule-out criteria; VTE, venous thromboembolism.
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The pulmonary arteries are enhanced by contrast, but PEs appear as filling defects, as indicated by the yellow arrows.
Abbreviation: PE, pulmonary embolism.
Reprinted from Rosen's Emergency Medicine Concepts and Clinical Practice. 10th edition. Ron M. Walls, ed. Pulmonary embolism and deep vein
thrombosis. Christopher Kabrhel. Pages 1022-1041 Copyright 2023, with permission from Elsevier.
Unfractionated heparin IV 80 units/kg bolus followed by 18 units/hr Titrated every 6 hr based on aPTT No renal adjustment
Enoxaparin (LMWH) SubQ 1 mg/kg twice daily or 1.5 mg/kg/day 1 mg/kg twice daily or 1.5 mg/kg/day Requires renal adjustment
Warfarin Oral 2.5-5 mg with parenteral bridge Dose adjustments based on INR, Several factors affect therapeutic
with INR goal of 2-3 efficacy
Abbreviations: aPTT, activated partial thromboplastin time; DOAC, direct oral anticoagulant; INR, international normalized ratio; IV, intravenous; LMWH,
low-molecular-weight heparin; subQ, subcutaneously.
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pulmonary embolism. You began anticoagulation with LMWH. A Doppler study also revealed a DVT in
his left leg, and an echocardiogram depicted right ventricular strain. His troponin I returned normal. You
contacted your PERT team. This patient was intermediate-high risk, which now opened the debate for the
best management. Ultimately, because of the patient’s size, it was determined that a catheter embolectomy
was the best course. The procedure was performed, the patient did well, and was discharged to home.
The patient required anticoagulation, but the question arose as to which agent to use and the ideal
disposition. She met low-risk criteria by sPESI and she met the Hestia criteria for outpatient management.
You discussed the case with the PERT team, and with shared decision-making with the patient, she was
started on a DOAC and scheduled to follow up with the pulmonologist from the PERT team in 2 days.
For the 60-year-old woman who arrived via EMS cyanotic, tachypneic, and tachycardic…
This patient was clearly a high-risk pulmonary embolism patient, even without any diagnostic studies. A
right humeral intraosseous access was obtained. She became lethargic, with a progressively dropping
respiratory rate. She underwent rapid sequence intubation with ketamine and rocuronium, and her
oxygenation improved to a pulse oximetry of 85% on 100% bag-valve mask ventilation, with an end-tidal
CASE 3
carbon dioxide level of 60 mm Hg. A right internal jugular catheter was placed and she was administered
alteplase 50 mg IV over 2 hours. A portable chest x-ray was negative. Bedside echocardiography
demonstrated a dilated right ventricle. The patient’s oxygen saturation gradually improved to 95%, and CO2
level decreased to 40 mm Hg. She was transferred to the CT scanner, where a pulmonary saddle embolism
was identified. Her blood pressure stabilized at 100/70 mm Hg, and her heart rate decreased to 110 beats/
min. Her oxygen continued to improve over the next 3 hours and she was transferred to the intensive
care unit. Following a rocky 1 month hospitalization, the patient was discharged home with a return to
premorbid baseline health status.
1. “The patient had normal vital signs, they could 6. “The patient met most of the Hestia criteria
not have a pulmonary embolism.” Abnormal vi- for outpatient management, isn’t that good
tal signs are of value in alerting a clinician to look enough?” For outpatient management of
for a pulmonary embolism, but the reverse is not pulmonary embolus patients, it is prudent to be
true. Patients with pulmonary emboli can have certain that discharged patients meet all of the
normal vital signs. Hestia criteria or some other outpatient scoring
system. This diagnosis has the potential to take
2. “She had no pleuritic chest pain, so a pulmo- a downward turn very quickly, so it is best to
nary embolism should not be on the differen- be conservative regarding which patients are
tial.” Pleuritic chest pain occurs in less than 50% admitted and which are sent home.
of patients, while nonpleuritic chest pain can
occur in 17% of cases. 7. “I started the patient on warfarin, so he was
anticoagulated.” Warfarin is a vitamin K antago-
3. “The onset of shortness of breath was over nist, and it takes time to become effective. If it is
days. That is not how a pulmonary embolism to be used for pulmonary embolism patients, a
presents.” It is true that approximately 67% of bridge with a rapid-acting anticoagulant must be
patients with a pulmonary embolism will describe used until the warfarin becomes therapeutic.
their dyspnea as “sudden” in onset, occurring
within minutes, but this still leaves a gradual 8. “The patient’s rGeneva score was 4. That is
onset occurring in about one-third of cases. almost low-risk.” Low-risk is ≤3. You can state in
your note that the patient was intermediate-risk
4. “It doesn't matter what the patient’s blood but you decided that the entire clinical picture
pressure showed, or her normal troponin and did not warrant further workup, but do not state
BNP. There was a large clot on the CTPA and the patient was “almost” low-risk.
a dilated right ventricle. She needed tPA.” In
patients who are stable, low-risk, or intermediate- 9. “The patient’s chest pain was clearly cardiac,
low risk, the value of tPA is not well established. and I ruled them out with a negative troponin
There is real risk for bleeding with tPA, as well. At test and an ECG.” The pain from a pulmonary
present, tPA should be used only in high-risk pa- embolism can mimic that from an acute myocar-
tients and should be considered in intermediate- dial infarction. Just because you have ruled out
high risk patients. one does not mean you do not need to consider
the other.
5. “I am an emergency physician. I can manage
my patients without a PERT team.” It may not 10. “I didn’t think the recent surgery was an is-
be the standard of care to consult a PERT team sue. The patient needed tPA.” If the patient is
for every pulmonary embolism patient; however, high risk and has an absolute contraindication to
getting expert consultants involved in the care tPA, then the clinician should attempt to arrange
of a patient, especially one who is not low-risk, is another approach, which might include catheter-
always a good idea. directed tPA or a thrombectomy.
NO YES YES NO
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2023 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.
YES YES NO
Systemic thrombolysis,
full or reduced dose
(Class III)
YES NO
D-dimer <1000
Positive for deep vein thrombosis? NO D-dimer <500 ng/mL?
ng/mL?
*YEARS criteria:
• Clinical signs of deep vein thrombosis
• Hemoptysis
• Pulmonary embolism is the most likely diagnosis
EDITOR-IN-CHIEF Daniel J. Egan, MD Charles V. Pollack Jr., MA, MD, CRITICAL CARE EDITORS
Andy Jagoda, MD, FACEP Harvard Affiliated Emergency FACEP, FAAEM, FAHA, FACC, William A. Knight IV, MD,
Professor and Chair Emeritus, Medicine Residency, FESC FACEP, FNCS
Department of Emergency Massachusetts General Hospital/ Clinician-Scientist, Department Associate Professor of
Medicine; Director, Center for Brigham and Women's Hospital, of Emergency Medicine, Emergency Medicine and
Emergency Medicine Education Boston, MA University of Mississippi School Neurosurgery, Medical Director,
and Research, Icahn School of of Medicine, Jackson MS EM Advanced Practice Provider
Marie-Carmelle Elie, MD
Medicine at Mount Sinai, New Professor and Chair, Department Ali S. Raja, MD, MBA, MPH Program; Associate Medical
York, NY of Emergency Medicine Executive Vice Chair, Emergency Director, Neuroscience ICU,
ASSOCIATE EDITOR-IN-CHIEF University of Alabama at Medicine, Massachusetts General University of Cincinnati,
Birmingham, Birmingham, AL Hospital; Professor of Emergency Cincinnati, OH
Kaushal Shah, MD, FACEP Medicine and Radiology, Harvard
Assistant Dean of Academic Nicholas Genes, MD, PhD Scott D. Weingart, MD, FCCM
Medical School, Boston, MA Editor-in-Chief, emCrit.org
Advising, Vice Chair of Clinical Assistant Professor,
Education, Professor of Ronald O. Perelman Department Robert L. Rogers, MD, FACEP, PHARMACOLOGY EDITOR
Clinical Emergency Medicine, of Emergency Medicine, NYU FAAEM, FACP
Grossman School of Medicine, Assistant Professor of Emergency Aimee Mishler, PharmD, BCPS
Department of Emergency
New York, NY Medicine, The University of Emergency Medicine Pharmacist,
Medicine, Weill Cornell School of
Maryland School of Medicine, St. Luke's Health System,
Medicine, New York, NY Michael A. Gibbs, MD, FACEP
Baltimore, MD Boise, ID
EDITORIAL BOARD Professor and Chair, Department
RESEARCH EDITOR
of Emergency Medicine, Alfred Sacchetti, MD, FACEP
Saadia Akhtar, MD, FACEP Carolinas Medical Center, Assistant Clinical Professor, Joseph D. Toscano, MD
Associate Professor, Department University of North Carolina Department of Emergency Chief, Department of Emergency
of Emergency Medicine, School of Medicine, Medicine, Thomas Jefferson Medicine, San Ramon Regional
Associate Dean for Graduate Chapel Hill, NC University, Philadelphia, PA Medical Center, San Ramon, CA
Medical Education, Program
Director, Emergency Medicine Steven A. Godwin, MD, FACEP Robert Schiller, MD INTERNATIONAL EDITORS
Residency, Mount Sinai Beth Professor and Chair, Department Chair, Department of Family
Peter Cameron, MD
Israel, New York, NY of Emergency Medicine, Medicine, Beth Israel Medical
Academic Director, The Alfred
Assistant Dean, Simulation Center; Senior Faculty, Family
William J. Brady, MD, FACEP, Emergency and Trauma Centre,
Education, University of Medicine and Community
FAAEM Monash University, Melbourne,
Florida COM-Jacksonville, Health, Icahn School of Medicine
Professor of Emergency Medicine Australia
Jacksonville, FL at Mount Sinai, New York, NY
and Medicine; Medical Director, Andrea Duca, MD
Emergency Management, Joseph Habboushe, MD MBA Scott Silvers, MD, FACEP
Attending Emergency Physician,
UVA Medical Center; Medical Assistant Professor of Clinical Associate Professor of
Ospedale Papa Giovanni XXIII,
Director, Albemarle County Fire Emergency Medicine, Emergency Medicine, Chair of
Bergamo, Italy
Rescue, Charlottesville, VA Department of Emergency Facilities and Planning, Mayo
Medicine, Weill Cornell School Clinic, Jacksonville, FL Suzanne Y.G. Peeters, MD
Calvin A. Brown III, MD of Medicine, New York, NY; Co- Attending Emergency Physician,
Director of Physician Corey M. Slovis, MD, FACP,
founder and CEO, MDCalc Flevo Teaching Hospital, Almere,
Compliance, Credentialing FACEP
The Netherlands
and Urgent Care Services, Eric Legome, MD Professor and Chair Emeritus,
Department of Emergency Chair, Emergency Medicine, Department of Emergency Edgardo Menendez, MD,
Medicine, Brigham and Women's Mount Sinai West & Mount Sinai Medicine, Vanderbilt University FIFEM
Hospital, Boston, MA St. Luke's; Vice Chair, Academic Medical Center, Nashville, TN Professor in Medicine and
Affairs for Emergency Medicine, Emergency Medicine; Director of
Peter DeBlieux, MD Stephen H. Thomas, MD, MPH
Mount Sinai Health System, Icahn EM, Churruca Hospital of Buenos
Professor of Clinical Medicine, Department of Emergency
School of Medicine at Mount Aires University, Buenos Aires,
Louisiana State University School Medicine, Beth Israel Deaconess
Sinai, New York, NY Argentina
of Medicine; Chief Experience Medical Center and Harvard
Officer, University Medical Keith A. Marill, MD, MS Medical School, Boston, MA Dhanadol Rojanasarntikul, MD
Center, New Orleans, LA Associate Professor, Department Attending Physician, Emergency
Ron M. Walls, MD
of Emergency Medicine, Harvard Medicine, King Chulalongkorn
Deborah Diercks, MD, MS, Professor and COO, Department
Medical School, Massachusetts Memorial Hospital; Faculty
FACEP, FACC of Emergency Medicine, Brigham
General Hospital, Boston, MA of Medicine, Chulalongkorn
Professor and Chair, Department and Women's Hospital, Harvard
University, Thailand
of Emergency Medicine, Angela M. Mills, MD, FACEP Medical School, Boston, MA
University of Texas Southwestern Professor and Chair, Department Edin Zelihic, MD
Medical Center, Dallas, TX of Emergency Medicine, Head, Department of Emergency
Columbia University Vagelos Medicine, Leopoldina Hospital,
College of Physicians & Schweinfurt, Germany
Surgeons, New York, NY
Evidence-Based Management
of Pulmonary Embolism in
the Emergency Department
AUGUST 2023 | VOLUME 25 | ISSUE 8
Points
• Even with appropriate care, approximately 15%-
Pearls
30% of patients with pulmonary embolism (PE) • The most common risk factors for PE are fe-
will die within 90 days,1-3 potentially from the un- male sex, immobilization, recent surgery, ma-
derlying medical pathology that led to the clot. lignancy, and travel >4 hours in the previous
• Chest pain, dyspnea, and hemoptysis are com- month. Table 1 lists other clinical risk factors.
mon signs of PE; establishing the time of onset of • Primary pulmonary pathologies such as COPD,
symptoms can help determine the cause. asthma, pneumonia, pneumothorax, and
• Isolated syncope with no other symptoms sug- pleuritis should be on the differential for sus-
gestive for PE is not an indication for an evalua- pected PE.
tion for thromboembolic disease. • Vital signs in PE may be normal; hypotension is
• Other findings in PE include tachypnea, tachycar- the least specific vital sign (5%).20
dia, cyanosis, lower extremity edema, and deep • Clinical gestalt alone demonstrates poor
vein thrombosis. performance in excluding the need for further
• Scoring systems for determining clinical pretest testing.25,26
probability include the Wells, rGeneva, PERC, • D-dimer assays should be used in combination
and YEARS criteria. (See Table 2.) with a patient‘s clinical pretest probability to
• Electrocardiogram is useful, though not diagnos- determine whether PE can be ruled out or ad-
tic, with 25% of patients having normal tracings.27 ditional diagnostic studies are needed.29
• Age-adjusted D-dimer should be used. • CTPA is sensitive and specific for the presence
• D-dimer levels change with duration of the clot.29 of clots in the pulmonary vascular tree.39,40
• Serum troponin levels32 and elevations in serum Figure 1 shows PEs on CTPA.
natriuretic peptide levels are more valuable as • Maintaining pulse oximetry >95 is the treat-
prognostic for severity of illness and mortality ment goal, delivered via nasal cannula, high-
than in diagnosis of PE. flow nasal cannula, or noninvasive positive-
• Chest radiographs have little value in confirming pressure ventilation.
or excluding PE; however, they may be helpful in • Anticoagulation is the mainstay of treatment to
identifying alternative pathology.35-38 prevent further clot propagation. See Table 6
• The estimated glomerular filtration rate (eGFR) for recommendations for initial anticoagulant
can be used as a risk stratification tool to predict therapy.
contrast-induced nephropathy following comput-
ed tomographic pulmonary arteriography (CTPA).
• Concomitant lower extremity DVTs and PEs can interventionalist clinician to administer.
occur in 40%-70% of patients.49 • Thrombectomy, operative thoracotomy, and
• A multiorgan point-of-care ultrasound protocol of extracorporeal membrane oxygenation (ECMO)
examination of the heart, lungs, and leg has 90% may be options for some patients, as available.
sensitivity and 86% specificity for PE.50 • The pulmonary embolism response team (PERT) is
• Prognostic risk classifications use physiologic and a multidisciplinary team of clinicians that assists in
diagnostic criteria to determine severity of PE. coordination of care in institutions where available.
Tables 3, 4, and 5 present 3 classification systems. • PE in pregnant patients is a significant cause of
• Fluid management and vasoactive agents may be maternal mortality. Though low-molecular weight
appropriate in some circumstances. heparin can be given to low-risk patients, higher
• Systemic thrombolytics are reserved for use in un- risk patients require input from a PERT team or
stable patients. See Table 7 for contraindications. multiple consultants.
• Thrombolytics can be delivered via pulmo- • Patients meeting Hestia criteria (see Table 8) may
nary artery catheter, but this use requires an be candidates for outpatient management.