Evidence-Based Management of Pulmonary Embolism in the Emergency Department

Table of Contents

 

About This Issue

No single sign or symptom is completely reliable in confirming or excluding a diagnosis of pulmonary embolism, and clinical gestalt alone has shown poor performance in determining the need for further testing. With symptoms of pulmonary embolism overlapping with many other cardiovascular and respiratory conditions, diagnosis can be challenging. In this issue, you will learn:

The most common risk factors for pulmonary embolism

The questions to ask of a patient with dyspnea or chest pain: time of onset; type of pain; lower extremity edema; recent surgery, travel, or immobility?

The specific criteria for 4 major clinical pretest scoring systems: Wells, rGeneva, PERC, and YEARS, how they determine the patient’s risk, and how the risk level can be used to determine testing options

How to use the age-adjusted D-dimer assay to assess risk

Using CT pulmonary angiograms to detect emboli, and the role of ECG, ultrasonography, and radiographs

Determining treatment based on risk stratification, including sPESI and Bova scores

Anticoagulants, thrombolytics, thrombolysis, thrombectomy, and thoracotomy: when each will be indicated

How to manage the specific needs of pregnant patients with pulmonary embolism

Which patients may be candidates for outpatient management

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Risk Factors for Pulmonary Emboli
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Vital Signs
      2. Other Physical Examination Findings
   3. Diagnostic Risk Scoring Systems
10. Diagnostic Studies
    1. Electrocardiogram
    2. Laboratory Studies
       1. D-dimer Assay
       2. Serum Troponin and Natriuretic Peptides
    3. Imaging Studies
       1. Chest Radiograph
       2. Computed Tomography
          • Risks of Iodinated Contrast
       3. Point-of-Care Ultrasonography
       4. Pulmonary Perfusion Study
       5. Pulmonary Angiography
       6. Magnetic Resonance Angiography
    4. Risk Stratification Categorization
11. Treatment
    1. Fluid Management
    2. Vasoactive Agents
    3. Anticoagulation
    4. Thrombolytics
       1. Catheter-Directed Thrombolysis
    5. Thrombectomy
    6. Operative Thoracotomy
    7. Extracorporeal Membrane Oxygenation
    8. Patient Management
12. Special Populations
    1. Pulmonary Embolism in Pregnant Patients
    2. Pulmonary Embolism and COVID-19 Patients
13. Controversies and Cutting Edge
14. Disposition
15. Summary
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Pulmonary Embolism in the Emergency Department
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for the Diagnostic Approach to Pulmonary Embolism Management
    2. Clinical Pathway for Risk-Directed Management of Pulmonary Embolism
    3. Clinical Pathway for Emergency Department Management of Pulmonary Embolism in Pregnant Patients
21. Tables and Figures
22. References

Abstract

Patients with pulmonary emboli present both diagnostic and therapeutic challenges to the emergency clinician, because initial symptoms can be variable and overlap with other medical conditions. This issue reviews treatment options for patients with pulmonary emboli based on risk stratification scores of low, intermediate-low, intermediate-high, and high risk classifications. The evidence on laboratory testing and imaging is presented, as well as treatment strategies that include anticoagulation, thrombolytics, and mechanical or surgical thrombectomy. Management decisions regarding pregnancy and COVID-19 are discussed, as well as considerations for outpatient treatment of low-risk patients.

Case Presentations

An obese 55-year-old man reports exertional dyspnea that began 2 days prior…

• The man says he is generally active, despite being obese, and says that he walks extensively for his job.
• His ECG is normal sinus rhythm at 95 beats/min and his resting pulse oximetry is at 94%. There are no other abnormalities. Chest x-ray, natriuretic peptide, and high-sensitivity troponin are normal.
• All of his symptoms can be explained by his weight, but you wonder whether you should start down a diagnostic pulmonary embolism algorithm...

A 65-year-old woman presents with a complaint of shortness of breath she developed that morning…

• She says she recently recovered from COVID-19 disease and was doing well prior.
• On examination, her lungs have a few residual ronchi from her illness, but are otherwise clear. Vital signs are normal, and her pulse oximetry is 97% on room air. As part of her workup, a D-dimer is ordered and returns incalculably high. She has a well-documented IV contrast allergy. A pulmonary perfusion scan was ordered, which shows a clear perfusion defect consistent with a pulmonary embolism.
• You consider whether this patient is a candidate for outpatient treatment and which medications to use...

A 60-year-old woman presents in extremis via basic EMS…

• She was recently released from the hospital following a 1-week hospitalization for COVID-19 disease, during which she was placed on low-molecular-weight heparin (LMWH). She stopped the LMWH 4 days prior. She said she developed severe shortness of breath about 1 hour ago when she stood up from a recliner she had been resting in.
• On arrival to the ED, she was cyanotic, tachypneic, tachycardic, and verbalizing “I can’t breathe” repeatedly. Initial pulse oximetry was 70%, with a sinus tachycardia of 130 beats/min and a blood pressure of 84/40 mm Hg.
• Does this patient require endotracheal intubation, and should thrombolytics be started immediately?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Westafer LM, Long B, Gottlieb M. Managing pulmonary embolism. Ann of Emerg Med. 2023:1-9. (Review) DOI: 10.1016/j.annemergmed.2023.01.019

13. * Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871-879. (Analysis of prospective data base; 824 patients) DOI: 10.1016/j.amjmed.2007.03.024

15. * Badertscher P, du Fay de Lavallaz J, Hammerer-Lercher A, et al. Prevalence of pulmonary embolism in patients with syncope. J Am Coll Cardiol. 2019;74(6):744-754. (Prospective observational study; 1380 patients) DOI: 10.1016/j.jacc.2019.06.020

18. * Kline JA, Corredor DM, Hogg MM, et al. Normalization of vital signs does not reduce the probability of acute pulmonary embolism in symptomatic emergency department patients. Acad Emerg Med. 2012;19(1):11-17. (Prospective observational study; 192 patients) DOI: 10.1111/j.1553-2712.2011.01253.x

30. * Iwuji K, Almekdash H, Nugent KM, et al. Age-adjusted D-dimer in the prediction of pulmonary embolism: systematic review and meta-analysis. J Prim Care Community Health. 2021;12:1-8. (Systematic review) DOI: 10.1177/21501327211054996

33. * Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. (Guidelines) DOI: 10.1093/eurheartj/ehz405

82. * Desai KR. Mechanical thrombectomy in pulmonary embolism: ready for prime time? JACC Cardiovasc Interv. 2021;14(3):330-332. (Opinion) DOI: 10.1016/j.jcin.2020.11.002

85. * Rivera-Lebron BN, Rali PM, Tapson VF. The PERT concept: a step-by-step approach to managing pulmonary embolism. Chest. 2021;159(1):347-355. (Review) DOI: 10.1016/j.chest.2020.07.065

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Keywords: pulmonary embolism, thrombus, lung, clot, chest, dyspnea, tachycardia, Wells, rGeneva, PERC, YEARS, D-dimer, CTPA, sPESI, Bova, anticoagulation, thrombolytic, thrombolysis