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General Medicine

Pulmonary Embolism

Reviewed 06/2018
 


BASICS

DESCRIPTION

  • Pulmonary embolism (PE) is the most serious presentation of venous thromboembolism (VTE).

  • Mortality exceeds 15% during the first 3 months. In 25% of patients, first manifestation is s...

DIAGNOSIS

  • Establish a pretest probability based on clinical criteria (2).

    • Wells score

      • Clinical signs and symptoms of DVT +3

      • Alternative diagnosis is less likely than PE +3.

      • Heart rate >100 +1.5

      • Immo...

TREATMENT

MEDICATION

  • If clinical suspicion is high and no contraindications, start treatment immediately.

  • Start LMWH, fondaparinux, UFH, as initial therapy for first 5 to 10 days. VKA can be started the...

ONGOING CARE

Duration of anticoagulation 

  • Provoked PE (trigger no longer present): 3 months (1)[B]

  • Unprovoked PE: Minimum of 3 months, consider long-term or prolonged secondary prophylaxis if bleeding r...

REFERENCES

1
Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J.  2014;35(43):3033–3069, 3069a–3069k. [V...

CODES

ICD10

  • I26.99 Other pulmonary embolism without acute cor pulmonale

  • I27.82 Chronic pulmonary embolism

ICD9

  • 415.19 Other pulmonary embolism and infarction

  • 416.2 Chronic pulmonary embolism

SNOMED

  • 59282003 ...

CLINICAL PEARLS

  • PE can be excluded in patients who have low pretest probability and negative D-dimer testing.

  • Perform cancer-oriented review of systems and age/gender-appropriate cancer screening in pa...

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FIGURE 1.3. Ventilation-perfusion imaging in diagnosis of pulmonary embolism. A:Ventilation image, obtained with 99mTc pentetate aerosol, shows homogenous ventilation on posterior view. B: Matched perfusion image shows large (segmental) perfusion defects in the left mid lung, and in the lateral segment of the left lower lobe. There is also decreased perfusion in the right upper lobe. The presence of unmatched segmental abnormalities indicates a high probability for pulmonary embolism.
FIGURE 1.3. Ventilation-perfusion imaging in diagnosis of pulmonary embolism. A:Ventilation image, obtained with 99mTc pentetate aerosol, s...
FIGURE 36.2. Bilateral pulmonary embolism (arrows) demonstrated by contrast-enhanced spiral computed tomography scan.
FIGURE 36.2. Bilateral pulmonary embolism (arrows) demonstrated by contrast-enhanced spiral computed tomography scan.
Figure 13.5 Contrast enhanced multirow (16-slice) detector chest CT in a patient with acute pulmonary embolism. In the coronal reconstructed view, multiple segmental emboli can be visualized (arrows). (Figure kindly provided by Joseph Schoepf, MD, Department of Radiology, Brigham and Women’s Hospital, Boston, MA.)
Figure 13.5 Contrast enhanced multirow (16-slice) detector chest CT in a patient with acute pulmonary embolism. In the coronal reconstructe...
Figure 13.7 Primary evidence of acute pulmonary embolism. Selective cut-film angiogram of the right lower lobe pulmonary artery with multiple intraluminal radiolucencies, almost completely outlined by contrast (left). Corresponding segmental perfusion defects of the right lower lobe (right).
Figure 13.7 Primary evidence of acute pulmonary embolism. Selective cut-film angiogram of the right lower lobe pulmonary artery with multip...
Echocardiography in a patient with massive pulmonary embolism. The right ventricle (RV) is markedly enlarged, flattening the intraventricular septum and compromising the left ventricle (LV).
Echocardiography in a patient with massive pulmonary embolism. The right ventricle (RV) is markedly enlarged, flattening the intraventricul...
Figure 1.25. Ventilation-perfusion scan in a patient with pulmonary emboli. A. Perfusion scan of the lungs shows many areas devoid of radioisotope (photopenia) bilaterally. B. The ventilation scan is normal. This combination of findings is diagnostic of pulmonary embolism.
Figure 1.25. Ventilation-perfusion scan in a patient with pulmonary emboli. A. Perfusion scan of the lungs shows many areas devoid of radio...
Fig C 1-22 Pulmonary infarction. (A) Chest film made 3 days after open-heart surgery demonstrates a very irregular opacity at the right base (pneumonia versus pulmonary embolization with infarction). (B) On a film made 5 days later, the consolidation is seen to have reduced in size yet to have retained the same general configuration as on the initial view. The diagnosis of pulmonary embolism was confirmed by a radionuclide lung scan.5
Fig C 1-22 Pulmonary infarction. (A) Chest film made 3 days after open-heart surgery demonstrates a very irregular opacity at the right bas...
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