We review the diagnosis, risk stratification, & management of acute pulmonary embolism in the ED.
Hosts:
Vivian Chiu, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Pulmonary_Embolism.mp3
Download
Leave a Comment
Tags:
Pulmonary
Show Notes
Core Concepts and Initial Approach
* Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli.
* Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually.
* Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision.”
* Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy.
Clinical Presentation and Risk Stratification
* Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse.
* Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever.
* Chronic: Can mimic acute symptoms or be totally asymptomatic.
* Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion.
* High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15 minutes), requirement of vasopressors, or signs of shock → activate PERT team immediately.
* Crucial Mimics: Think broadly; consider pneumonia, ACS, pneumothorax, heart failure exacerbation, and aortic dissection.
Workup & Diagnostics
* History/Scoring: Ask about prior clots, recent surgeries, hospitalizations, travel. Use Wells/PERC criteria to assess pretest probability.
* Labs:
* D-dimer: A good test to rule out PE in a patient with low probability. If suspicion is high, proceed directly to imaging.
* Troponin/BNP: Act as RV stress gauges. Elevated levels are associated with increased risk of a complicated clinical course (25-40%).
* Lactate: Helpful in identifying patients in possible cardiogenic shock.
* EKG: Most common finding is sinus tachycardia. Classic RV strain patterns (S1Q3T3, T-wave changes/inversions) are nonspecific.
* Imaging:
* CXR: Usually normal, but quick and essential to rule out other causes.
* CTPA: The usual standard and gold standard for stable patients. High sensitivity (> 95%) and can detect RV enlargement/strain.
* V/Q Scan: Option for patients with contraindications to contrast (e.g., severe contrast allergies).
* POCUS (Point-of-Care Ultrasound): Useful adjunct for unstable patients.
* Bedside Echo: Can show signs of RV strain (enlarged RV, McConnell sign).
* Lower Extremity Ultrasound: Can identify a DVT in ...
