Excluding the Diagnosis of Pulmonary Embolism:

Is There a Magic Ball?

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Guys:I am in our observation unit and I need some sage advice to settle a disagreement. I

just saw a 48-year-old woman who was admitted last night with left pleuritic chest

pain. She has had 5 days of URI symptoms with hacking nonproductive cough. Her

medical history is unremarkable and she has no history of VTE or PE, no recent

surgery or immobilization, no hemoptysis. She has no history of cancer.

Exam:•Afebrile

•BP 130/70

•HR 90 bpm•Lungs clear with scattered wheeze.

•Cardiac rhythm regular

•Heart sounds normal (no murmur)

•Extremity exam is normal

•O2 sat 95%

•CXR: clear lung fields

So hear is the rub:

I am concerned about the pleuritic nature of the chest pain. While my suspicion is

that her symptoms are due to a viral upper respiratory tract infection I think that she

needs a CT pulmonary angiogram to be as sure as possible that she doesn’t have a

pulmonary embolus. My partner says no, a high sensitivity D-Dimer should be done

and only if that is elevated should a CT pulmonary angiogram be done. Our resident

says that no test is necessary because the likelihood of this being a pulmonary

embolus is low.

Can you guys direct us on this one?

Guys:I am in our observation unit and I need some sage advice to settle a disagreement. I

just saw a 48-year-old woman who was admitted last night with left pleuritic chest

pain. She has had 5 days of URI symptoms with hacking nonproductive cough. Her

medical history is unremarkable and she has no history of VTE or PE, no recent

surgery or immobilization, no hemoptysis. She has no history of cancer.

Exam:•Afebrile

•BP 130/70

•HR 90 bpm•Lungs clear with scattered wheeze.

•Cardiac rhythm regular

•Heart sounds normal (no murmur)

•Extremity exam is normal

•O2 sat 95%

•CXR: clear lung fields

So hear is the rub:

I am concerned about the pleuritic nature of the chest pain. While my suspicion is

that her symptoms are due to a viral upper respiratory tract infection I think that she

needs a CT pulmonary angiogram to be as sure as possible that she doesn’t have a

pulmonary embolus. My partner says no, a high sensitivity D-Dimer should be done

and only if that is elevated should a CT pulmonary angiogram be done. Our resident

says that no test is necessary because the likelihood of this being a pulmonary

embolus is low.

Can you guys direct us on this one?

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Patient

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Very low:

No further testing neededLow to Intermediate:

D-dimer helps with the risk stratificationHigh likelihood:

Proceed to imaging

(CT Pulmonary Angiogram)

Probability of Pulmonary Embolism

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Why Not CT Scan Everyone?

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Increased use has not led to improved patient outcome

With increased use in ED leading to increased

detection there has been

no reduction in mortalityRadiation exposureCost

*

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Our patient = 0: Low risk

Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

Ann Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Our patient = 0: Low risk

Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the

American College of PhysiciansAnn Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Copyright © 2015

Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of

PhysiciansAnn Intern Med. 2015;163(9):701-711. doi:10.7326/M14-1772

Pathway for the evaluation of patients with suspected PE.PERC = Pulmonary Embolism Rule-Out Criteria.

* Using either a clinical decision tool or gestalt.PE = pulmonary embolism;

Figure Legend:

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Pearls

Use validated clinical prediction rules to estimate pretest probability

Do not obtain D-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all PERC

Obtain a high sensitivity D-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with a low pretest probability of PE who do not meet all PERC

Copyright © 2015

Pearls

Do not use imaging tests as the initial test in patients who have a low or intermediate pretest probability of PE

When a D-dimer is indicated age adjust it in patients older than 50 (top normal = age x 10ng/ml)

Do not obtain an imaging study in patients with a D-dimer below the age adjusted cut off

Do not obtain D-dimer in patients with a high probability of PEObtain a CT Pulmonary angiogram in patients with high

probability PEReserve V/Q scans for high pretest probability patients who have

contraindications to CTPA or if CTPA is indicated but not available

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