← Diagnosis and Management Guides
Pulmonary Embolism
Key considerations: Massive PE with shock, Saddle PE, Right heart strain
Cannot miss
- Massive PE with shock
- Saddle PE
- Right heart strain
Likely diagnoses
- Acute PE
- Pneumonia
- Pleuritis
- Anxiety/hyperventilation
- Pneumothorax
Red flags
- Hypotension
- Severe hypoxia
- RV dilation
- Elevated troponin
Workup
- history: Acute dyspnea, pleuritic chest pain, hemoptysis, leg swelling, risk factors (immobility, surgery, cancer, OCPs); exam: Tachycardia, tachypnea, hypoxia, JVD, RV heave, unilateral leg swelling; labs: D-dimer (if low pretest probability); Troponin, BNP (prognostic); ABG; imaging: CT pulmonary angiography (gold standard); V/Q scan if CTA contraindicated; Lower extremity US if DVT suspected; bedside: POCUS: RV dilation, McConnell sign, clot in transit
Management
- immediate: Anticoagulation: heparin or DOAC; Massive PE + shock: systemic tPA (alteplase 100mg IV over 2hr); Submassive PE: consider catheter-directed therapy; general: Risk stratify: sPESI, troponin, BNP, RV function; Duration: 3 months minimum (longer if unprovoked or cancer)
Disposition
- admit: All PE patients initially (submassive/massive to ICU); Low-risk PE (sPESI 0): may consider outpatient with DOAC; discharge: Low-risk PE with close follow-up and DOAC; consults: Pulmonology, interventional radiology for catheter-directed therapy, hematology for thrombophilia
Clinical pearls
- PERC rule: if ALL 8 criteria negative, PE effectively ruled out without D-dimer
- RV dilation on CT or echo = submassive PE even if hemodynamically stable
Source and review
- AHA PE Guidelines 2019. Last reviewed: 2024-11-01