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Pulmonary Embolism

Pulmonary Embolism. Suspecting and diagnosing acute pulmonary embolism. Signs and Symptoms of PE. Dyspnea (sudden or gradual onset)* Orthopnea* Chest pain (usually pleuritic)* Tachycardia Hypoxia Coughing/hemoptysis Syncope* Anxiety Tachypnea Diaphoresis Evidence of DVT*

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Pulmonary Embolism

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  1. Pulmonary Embolism Suspecting and diagnosing acute pulmonary embolism

  2. Signs and Symptoms of PE • Dyspnea (sudden or gradual onset)* • Orthopnea* • Chest pain (usually pleuritic)* • Tachycardia • Hypoxia • Coughing/hemoptysis • Syncope* • Anxiety • Tachypnea • Diaphoresis • Evidence of DVT* • Signs of RV overload on EKG (often nonspecific ST/T abnormalities)* • Fever*

  3. Risk factors for PE • Surgery or trauma • Prolonged immobility 0r obesity • Hypercoagulable state (malignancy, peripartum, nephrotic syndrome, thrombophilias) • Smoking • Previous DVT • Indwelling venous catheter • Medications (HRT, estrogen-containing compounds, chemotherapy, SERMs) • Increasing age

  4. PERC Rule • Age < 50 • Pulse oximetry > 94% • Heart rate < 100 bpm • No prior history of PE • No hemoptysis • No estrogen use • No unilateral leg swelling or clinical suspicion for DVT • No surgery or trauma (requiring hospitalization or intubation) within the last 4 weeks • If all are true, then no D-dimer is necessary and PE is ruled out. • If one or more is false, D-dimer is ordered. If D-dimer is positive, CTA is indicated. • *****If clinical suspicion is high despite results of PERC rule or D-dimer, further testing is indicated.

  5. Hints on CXR to suggest PE • Hampton’s hump • Pulmonary oligemia (Westermark’s sign) • Abrupt amputation of hilar artery (Knuckle sign) • Elevated diaphragm(s)/volume loss • Atelectasis (Fleischner lines) • Pleural effusion • Cardiomegaly • Interstitial edema

  6. Hampton’s hump

  7. Westermark’s sign

  8. Knuckle sign

  9. Fleischner lines

  10. ACR Appropriateness Criteria

  11. V/Q Scan with PE

  12. CTA with PE

  13. Resources • http://www.med.cmu.ac.th/student/rad/chest/p_embolism.htm • http://www.e-radiography.net/radpath/p/pe2.htm • http://www.guideline.gov/summary/summary.aspx?doc_id=10600 • http://ajrccm.atsjournals.org/cgi/content/full/159/3/864?view=full&pmid=10051264 • http://www.rhqn.org/resources/The Quandary of Considering Acute Pulmonary Embolism.doc • http://acsearch.acr.org/ProceduresList.aspx?tid=69068&vid=3072082

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