Pulmonary Embolism Moderate Probability Evaluation

Aka: Pulmonary Embolism Moderate Probability Evaluation, PE Moderate Probability Evaluation, Moderate PE Probability, Intermediate PE Probability, Moderate Clinical Suspicion for Pulmonary Embolism

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II. Technique

  1. Based on PE Probability (See PE Diagnosis)
    1. See Pulmonary Embolism Pretest Probability
    2. See Pulmonary Embolism Rule-Out Criteria (PERC Rule)
    3. See Wells Clinical Prediction Rule for PE
  2. Consider Alternative Diagnosis
    1. See Chest Pain Causes
    2. See Dyspnea Causes
    3. See Leg Pain Causes
    4. See Tachypnea
    5. See Hypoxia
    6. See Sinus Tachycardia

III. Evaluation: Step 1 - Determine if Deep Vein Thrombosis Present

  1. No Signs and Symptoms of DVT
    1. Jump to step 2 below
  2. Signs and Symptoms of DVT
    1. Lower Extremity DopplerUltrasound Positive for DVT
      1. Treat with Pulmonary Embolism Management
    2. Lower Extremity DopplerUltrasound Negative for DVT
      1. Move to step 2 below

IV. Evaluation: Step 2 - Imaging Study

  1. CT Pulmonary Angiogram (Spiral or helical chest CT, Preferred)
    1. Spiral Chest CT suggestive for PE (Positive)
      1. Treat with Pulmonary Embolism Management
    2. Spiral Chest CT not suggestive for PE (Negative)
      1. Consider jumping to step 3 below
      2. Negative spiral CT alone in a Moderate PE Probability is typically sensitive enough to exclude Clinically Significant PE
      3. Use clinical judgement in whether to pursue additional testing (D-Dimer, Ultrasound) when spiral CT is negative
  2. Ventilation Perfusion Scan (V/Q Scan)
    1. Indicated if CT Angiography Contraindicated
    2. Normal Probability V/Q Scan
      1. No further evaluation needed
      2. Evaluate for alternative diagnosis
    3. Low or Intermediate Probability VQ Scan
      1. Jump to Step 3 below
    4. High Probability V/Q Scan
      1. Treat with Pulmonary Embolism Management

V. Evaluation: Step 3 - Obtain Lower Extremity Compression Ultrasound

  1. Negative Compression Ultrasound
    1. D-Dimer positive
      1. PE in 1.8% if CT angiography and leg Ultrasound negative
        1. Musset (2002) Lancet 360:1914-20 [PubMed]
      2. Repeat Compression Ultrasound in one week (if asymptomatic, stable patient)
        1. Treat with Pulmonary Embolism Management if positive on repeat Ultrasound
    2. D-Dimer negative
      1. Evaluate for alternative diagnosis
  2. Positive Compression Ultrasound
    1. Treat with Pulmonary Embolism Management

VI. References

  1. Tabas in Majoewsky (2013) EM:Rap 13(6):8-10
  2. Ramzi (2004) Am Fam Physician 69:2829-36 [PubMed]
  3. Wells (1998) Ann Intern Med 129(12): 997-1005 [PubMed]
  4. Wilbur (2012) Am Fam Physician 86(10):913-9 [PubMed]

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