Sandbox chetan

Identify cardinal findings that increase the pretest probability of pulmonary embolism ❑ Dyspnea at rest or with exertion ❑ Pleuritic pain ❑ Cough ❑ Tachycardia ❑ Accentuated P2 ❑ Wheezing ❑ Tachypnea ❑ Syncope ❑ Decreased breath sounds ❑ Calf or thigh pain and swelling ❑ Edema, erythema, tenderness, or a palpable cord in the calf or thigh ❑ Recurrent miscarriage in a previously pregnant female

Does the patient have any of the following findings of massive pulmonary embolism that require urgent management? ❑ >2- Pillow orthopnea ❑ Hypotension ❑ Jugular venous distension ❑ Right-sided S3 ❑ Parasternal lift ❑ EKG demonstrates, ❑ Atrial arrhythmias ❑ Right bundle branch block ❑ Inferior Q-waves ❑ Precordial T-wave inversion and ST-segment changes ❑ ABG shows, ❑ Hypercapnia ❑ Combined respiratory and metabolic acidosis

Yes

No

❑ Perform D-dimer ❑ Erythrocyte agglutination assay (takes upto 2 min) ❑ Semi-quantitative latex agglutination assay (takes upto 5 min) ❑ Semi-quantitative rapid ELISA (takes upto 10 min) ❑ Qualitative rapid ELISA (takes upto 10 min) ❑ Quantitative latex agglutination assay (takes upto 15 min) ❑ Quantitative rapid ELISA (takes upto 30 min) ❑ V/Q scan

Proceed to the complete diagnostic approach below

PE confirmed if ❑ High clinical probability with high-probability V/Q scan has 95% chance of having PE

PE can not be excluded ❑ D-dimer level >500 ng/mL

PE excluded ❑ Normal V/Q scan ❑ Low clinical probability with low-probability V/Q scan has 4% chance of having PE ❑ D-dimer level <500 ng/mL excludes the diagnosis in low pretest probability

Proceed with the management

Perform CT Pulmonary angiography to confirm the diagnosis of PE

Proceed to the complete diagnostic approach below

Assess for presence of anticoagulation contraindication ❑ Major bleeding diathesis (e.g. coagulation defects, platelet count < 40,000) ƒ❑ Uncontrollable active bleeding state ❑ƒ Acute haemorrhagic stroke ƒ❑ Cerebral lesions at high risk of bleeding ❑ƒ Active ulcerative or angiodysplastic gastrointestinal disease ƒ❑ Proliferative diabetic retinopathy ƒ❑ Severe uncontrolled hypertension ƒ❑ Severe renal and/or hepatic dysfunction

Yes

No

IVC filter

Start Anticoagulation

Submassive PE

Massive PE

Assess clinically for evidence of increased severity

Evidence of shock (SBP <90 mmHg) or respiratory failure

Is thrombolytic contraindicated?

Yes

No

Surgical emblectomy or catheter based interventions

Hold anticoagulation, give thrombolytics then resume anticoagulations

Patient shows clinical improvement

No

Yes

Surgical emblectomy or catheter based interventions

Continue anticoagulation