Pulmonary Embolism (PE) Guide

Initial Evaluation

  • History: Dyspnea, pleuritic chest pain, hemoptysis, leg swelling, syncope, recent surgery, prolonged immobility, cancer, prior DVT/PE
  • Physical Exam: Tachypnea, tachycardia, hypoxia, signs of DVT (unilateral leg swelling/tenderness)

    • Workup

  • Risk Stratification Tools:
    • Wells Criteria
    • PERC Rule
      • If the patient is low risk for PE and none of the following criteria are met, no further workup for PE is indicated as the risk of PE is <2%
        • Age > 50
        • HR >= 100
        • Room air O2 sat < 95%
        • Unilateral leg swelling
        • Hemoptysis
        • Surgery or trauma < 4 weeks ago
        • Prior PE or DVT
        • Hormone use (think contraceptives)
  • Initial Testing:
    • EKG (sinus tachycardia, possible S1Q3T3 pattern)
    • Chest X-ray (often normal or nonspecific findings)
    • ABG (hypoxemia, respiratory alkalosis)
    • D-dimer (high sensitivity, low specificity)
  • Definitive Testing:
    • CT Pulmonary Angiography (gold standard)
    • V/Q Scan (if CT contraindicated)
    • Lower extremity Doppler ultrasound (if DVT suspected)
    • Echocardiography (for RV strain in massive PE)

Treatment

  • Stable Patients:
    • Anticoagulation (LMWH, heparin drip, or DOACs)
    • Consider outpatient treatment if low-risk (PESI score)
  • Submassive PE (RV strain, but normotensive):
    • Anticoagulation with heparin drip
    • Admission to tele or step down unit
    • Consider catheter-directed therapy based on risk/benefit
  • Massive PE (hypotension, shock):
    • IV fluids cautiously
    • ICU admission
    • Thrombolytics (tPA or TNK)
    • Consider embolectomy or catheter-directed therapy
    • Pressors for hemodynamic support
  • Additional Considerations: Oxygen, pain control, IVC filter (if anticoagulation contraindicated)

Disposition

  • Low-risk PE: Outpatient management possible with reliable follow-up
  • Moderate-risk PE: Admit to telemetry/floor with close monitoring
  • High-risk/Massive PE: ICU admission

References

  1. Konstantinides SV, Meyer G, Becattini C, et al. ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543–603.
  2. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging. Ann Intern Med. 2001;135(2):98–107.
  3. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315–352.