Pulmonary Embolism (in Adults)
- Annual incidence of 60 - 70 cases / 100 000
- Should assess clinical probability (simplified Wells Rule for PE) in conjunction with appropriate d-dimer assays.
Major risk factors for PE
Surgery
- Major abdominal / pelvic / knee surgery
- Post-op intensive care
Obstetrics
- Late pregnancy, Caesarian section
- Puerperium
Lower limb problems
- Fracture, Varicose veins
Malignancy
- Abdominal / pelvic
- Advanced / metastatic
Reduced mobility
- Hospitalisation
- Institutional care
Miscellaneous
- Previous proven VTE
Previous PE or DVT |
1 |
Heart Rate >100/min |
1 |
Surgery or immobilisation within 4 weeks |
1 |
Haemoptysis |
1 |
Active cancer |
1 |
Clinical signs of a DVT |
1 |
Alternative Dx less likely than PE |
1 |
Clinical probability |
|
PE unlikely |
≤1 |
PE likely |
>1 |
Management suspected non-massive PE
Most patients with PE are breathless and/or tachypnoeic>20/min
- In the absence of these , pleuritic chest pain or haemoptysis is usually due to another cause
Using Simplified Wells Score
PE unlikely A) Consider other diagnosis and B) Consider d-dimer testing
PE likely A) Consider direct imaging (e.g. CTPA, VQ, doppler venogram legs etc)
Most patients with PE are breathless and/or tachypnoeic>20/min
- In the absence of these , pleuritic chest pain or haemoptysis is usually due to another cause
Clinical probability in patients with possible PE may be assessed by asking
- Is another diagnosis unlikely (CXR & ECG are helpful)?
- Is there a major risk factor ( recent immobility / major surgery / lower limb trauma or surgery , pregnancy / post partum , major medical illness, previous proven VTE)
High probability - of the above 1 plus both another diagnosis unlikely and risk factor present
Intermediate probability - 1 plus either another diagnosis
Low probability - another diagnosis likely and no
Management probable massive PE
Massive PE likely if:
- Collapse/hypotension and
- Unexplained hypoxia , and
- Engorged neck veins , and
- Right ventricular gallop (often)
In stable patients where massive PE confirmed , iv dose of alteplase is 100 mg in 90 mins.
- Thrombolysis followed by unfractionated heparin in 3 hours
- Contraindications to thrombolysis should be ignored in life-threatening PE
- Out -of-hospital cardiac arrest patients with PE rarely recover.
