Pulmonary embolism diagnostic approach

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [2]

Overview

Signs and symptoms of pulmonary embolism are nonspecific; therefore, patients presenting with:

—should undergo diagnostic tests until the diagnosis is confirmed or eliminated or an alternative diagnosis is made.

CT equipped hospitals

In hospitals having experience in performing and interpreting CT Pulmonary angiography, following flowchart approach can be adopted.

 
 
 
 
 
 
 
Determine chances of PE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low chance
 
 
 
 
 
 
 
High chance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<500 ng/ml
 
>500 ng/ml
 
 
 
 
 
CT Pulmonary angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE excluded
 
 
 
 
 
 
Negative
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE excluded
 
 
PE confirmed

CT Non-equipped hospitals

Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) Study proposed the following, for hospitals who do not have sufficient resources to perform or interpret CT Pulmonary angiography.

Wells criteria are used to assess the clinical probability of PE and its graded as Low, Intermediate or High. later a ventilation-perfusion scan (V/Q) is performed, and based on the result of the scan PE is diagnosed.


The following table summarizes the possible outcome of V/Q scan:

V/Q Scan Clinical Probability Diagnosis
Normal any probability PE excluded
Low probability scan Low PE excluded
High probability scan High PE confirmed
Variable result/Non diagnostic Variable Serial lower extremity USG or Pulmonary angiography


Low risk outpatient population

In populations where the PE prevalence is low, the following eight factors constitute the PE rule-out criteria (PERC):

  • Age less than 50 years
  • Heart rate less than 100 bpm
  • Oxyhemoglobin saturation ≥95 percent
  • No hemoptysis
  • No estrogen use
  • No prior DVT or PE
  • No unilateral leg swelling
  • No surgery or trauma requiring hospitalization within the past four weeks.

This approach was tested in a multicenter study involving 8138 outpatients with suspected PE.[1] It was suggested, that when combined with a clinical assessment of low risk for PE, this approach can exclude PE without additional diagnostic testing. In clinical settings with a higher prevalence of PE (>20%), the PERC based approach has significantly poor predictive value.

References

  1. Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". J. Thromb. Haemost. 6 (5): 772–80. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)

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