Points to focus upon
How common is this:
Pulmonary embolism is a relatively rare diagnosis (0.08%) in the emergency department, however, due to the potential for adverse outcomes, it is important to maintain a high degree of suspicion among vulnerable populations.1 Approximately half of the patients are admitted to hospital in Canada, although this proportion is much higher in the USA (90%).2,3
DDx that present similarly:
Highly variable presentation – DDx will depend on presenting complaint, however, the main concerns are typically: ACS, Pericarditis, Pneumonia, Asthma/COPD Exacerbation, Pneumothorax, Rib Fracture, Costochondritis, Anxiety.
It is important to assess for DVT simultaneously.
Considerations in the age of COVID-19 for your safety:
The most common presenting complaints for PE are dyspnea and chest pain, both of which have been commonly observed in COVID-19 patients. Take appropriate precautions when assessing patients for these complaints.
- CBC, BUN/Cr, Lytes
- CXR, CTPA or V/Q scan
- Consider troponin and POCUS where applicable.
*ECG (up to 1/3 of patients): tachycardia, S1T3Q3T3, signs of pulmonary HTN/right heart strain (symmetrical T-wave inversion in anterior/inferior leads), new RBB
For stable outpatients starting anticoagulant therapy with follow-up in the community setting is very appropriate, even for those with pulmonary embolism. The PESI score can guide this decision, as will a conversation with the family physician or specialist who will be following this patient.
Oral Anticoagulation regimes usually include:
Warfarin (bridged with 5-7 days of Low Molecular Weight Heparin subcutaneous injections, eg. enoxaparin)
Direct Oral Anticoagulant (Dabigatran, Rivaroxaban, or Apixaban)
– Pregnant patients will require other forms of treatment such as low molecular weight heparin injections.
Read more here.
-Hemodynamic stabilization via supportive resuscitation
– Admission with monitoring
– Heparinzation is usually the mainstay of therapy and should be initiated in the ED. Choice of low molecular weight heparin (LMWH) vs. unfractionated heparin depends on various factors. Please refer to these recent guidelines (section XXV) for further details.
– May require consulting thrombosis/hematology/ICU service to discuss the role of targeted thrombolytics or other therapies.
Clinical Decision Rules:
- Wells Criteria for PE (not validated in pregnant patients)
- PERC Rule Out Criteria
- YEARS Algorithm (pregnant patients included in validation)
- PESI (outpatient vs inpatient management)
- sPESI (outpatient vs inpatient management)
Recommended readings, videos, and podcasts
- Antithrombotic Therapy for VTE Disease: CHEST Guideline & Expert Panel Report
- CRACKCast E088: PE & DVT
- Dyspnea/PE Overview – EMCases
- Diagnosing PE in Pregnancy – CanadiEM
- Managing PE in Pregnancy – CanadiEM
- PE – LITFL (Caution, Aussie content)
- Outpatient PE Management – EMDocs (Caution American content)
- Thrombolysis for PE – EMDocs (Caution American content)
- 1.Schissler AJ, Rozenshtein A, Schluger NW, Einstein AJ. National trends in emergency room diagnosis of pulmonary embolism, 2001–2010: a cross-sectional study. Respir Res. March 2015. doi:10.1186/s12931-015-0203-9
- 2.KOVACS MJ, HAWEL JD, REKMAN JF, LAZO-LANGNER A. Ambulatory management of pulmonary embolism: a pragmatic evaluation. Journal of Thrombosis and Haemostasis. July 2010:2406-2411. doi:10.1111/j.1538-7836.2010.03981.x
- 3.Mansour S, Alotaibi G, Wu C, McMurtry MS. Trends in admission rates and in-hospital stay for venous thromboembolism. Thrombosis Research. August 2017:149-154. doi:10.1016/j.thromres.2017.06.012