Pulmonary Embolism (PE)

Pulmonary Embolism:

Symptoms/Clues: pleuritic chest pain, long travel, immobile, SOB, tachypnea, tachycardia, hemoptosis, palpitations

  • Chest CT scan with IV contrast (or V/Q scan if cannot tolerate IV contrast)
    • CT angiography (CTA) of the chest (CT per PE protocol) – confirms PE, cannot rule out PE.
      • Doppler US of bilateral LE (even if negative CT of the chest!!!)***
  • D-dimer (helps rule out if low risk group) (normal < 230) (≥ +1,000 typically for PE)
  • Tx: Lovenox (Enoxaparin): Therapeutic: 1mg/kg/dose SubQ q12hrs
    • Or if kidney failure: Heparin drip 25,000U / NaCl 0.45% (500ml bag) IV @ titrate/hr
  • Tx time frame:
    • 1st clot, small, 1 location, unprovoked: 6 months of Warfarin
    • If PE & DVT, recurrent clots, if large, multiple locations: 1 year of Warfarin
      • Inpatient pain: Lortab 5PRN mild to moderate pain, Percocet severe pain.
      • Start Coumadin diet and provide Coumadin education.

Wells’ Criteria for PE:  http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/

Of note: Wells’ Criteria. Two separate sets of criteria.

  • One is for determining the risk of pulmonary embolism (PE)
  • The other is for determining the risk of deep vein thrombosis (DVT).
  • Clinical Signs and Symptoms of DVT (clinically suspected DVT): 3.0 points
  • PE is the #1 diagnosis (alternative diagnosis is less likely than PE): 3.0 points
  • Heart rate > 100: 1.5 points
  • Immobilization at least 3 days or Surgery in the previous 4 weeks: 1.5 points
  • History of DVT or PE: 1.5 points
  • Hemoptysis: 1.0 points
  • Malignancy (with treatment within 6 months) or palliative: 1.0 points
  • Traditional interpretation
  • Score > 6.0 — High (probability 59% based on pooled data)
  • Score 2.0 to 6.0 — Moderate (probability 29% based on pooled data)
  • Score < 2.0 — Low (probability 15% based on pooled data)

Alternative interpretation:

  • Score > 4 — PE likely. Consider diagnostic imaging.
  • Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.

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