Pulmonary Embolism Notes

Pulmonary Embolism

Clinical Judgement

  • Use clinical judgment in conjunction with tools like PERC, Wells criteria, and D-dimer.
  • Avoid anchoring bias.

Wells Criteria

The Wells criteria include:

  • Clinical signs and symptoms of DVT (Deep Vein Thrombosis).
  • PE is the #1 diagnosis, or equally likely.
  • Heart Rate (HR) > 100 bpm.
  • Immobilization for at least 3 days, or surgery in the past 4 weeks.
  • Previous DVT/PE.
  • Hemoptysis.
  • Cancer with treatment within the past 6 months or palliative care.

PERC Criteria

The PERC (Pulmonary Embolism Rule-out Criteria) include:

  • Age.
  • Heart Rate (HR).
  • Oxygen Saturation (O2 Sat).
  • Unilateral Leg Swelling.
  • Hemoptysis.
  • Recent Surgery/Trauma (≤4 weeks).
  • Prior PE/DVT.
  • Hormone use.

D-dimer

  • Age-adjusted D-dimer levels.
  • Consider pregnancy status when interpreting D-dimer results.

Case Examples

Case 1

  • A 52-year-old male with CAD presents with dizziness and shortness of breath with minimal activity.
  • Denies syncope, chest pain (CP), previous DVT/PE, malignancy, recent surgeries, immobilization.
  • Vitals: HR 91, BP 121/79, RR 15, O2Sat 94% on room air (RA).
  • Nurse notes: Placed on O2 due to shortness of breath when moving in bed.
  • Documented PE via Lungs CTA B/L; CV RRR, 2+ pulses in all extremities, tachypneic.
  • Troponin and BNP are slightly elevated.
  • Initially treated for NSTEMI and CHF.
  • Key point: Absence of chest pain argues against NSTEMI. An O2 saturation < 95% should raise suspicion for PE and shortness of breath may have other causes than cardiac. Elevated troponin doesn't always indicate MI, and elevated BNP doesn't always indicate CHF. Consider Wells and PERC, and avoid anchoring bias.

Case 2

  • A 19-year-old college student presents to ED with chest pain, cough, and dyspnea.
  • Initially given antibiotics and told to return if symptoms worsen.
  • Returns 2 days later, HR 107, BP 97/65.
  • Given an inhaler and discharged home.
  • Found dead the next morning.
  • Lawsuit resulted in a $7 million verdict against the hospital and ED physician.

Case 3

  • 38-year-old male presents with 2 days of right-sided flank pain, HR 120/min.
  • No chest pain, dyspnea, cough, fevers, syncope, or hematuria.
  • CT ordered to rule out renal colic; UA shows small amount of blood.
  • CT shows right lower lobe pneumonia.
  • Discharged home with fluids, antibiotics, and follow-up.

*Five days later, patient returns by EMS.
*Jumped out of bed and couldn’t breathe.
*HR 130, BP 89/46 RR 35.
*Sepsis order set and antibiotics started and sent to the ICU with a CTA to be done en route to the ICU.
*Diagnosed with a saddle PE, right heart strain, RLL infarct, and died the next day.
*Settled for 7 figures.

Cough, Dyspnea, Chest Pain

  • If you don’t think of PE, you will never diagnose it.
  • This does NOT mean ordering a CTA on every patient.
  • Consider PE and rule it out with your History and Physical exam (H&P).
  • Document pertinent negatives.
  • If you cannot remove PE from your differential diagnosis, order a D-dimer.

Physical Exam

  • Remember to examine the legs for signs of DVT.
  • Vital signs are vital; be particularly aware of tachycardia.