Understand the most lethal and sneaky diagnosis in acute care medicine.

1. Pulmonary Embolism
John Bielinski
www.Emergency-Medicine-Institute.com

2. What’s Inaccurate About
PEs?
• Most common complaint = SOB
• Most common EKG finding = S1Q3T3
• Most common ABG = R. Alkalosis
• Risk factors = Virchow’s Triad
• Best initial test = CTA
• Definitive test = Angiogram
• CXR Findings = Wedge shaped pleural
density or a central black area (Plus non-specific
findings)
– Hamptom’s Hump or Westermark’s Sign
• Treatment = Anticoagulation

3. Which is incorrect?
A. SOB
B. S1Q3T3
C. R. Alkalosis
D. CTA
E. Anticoagulation

4. ●Dyspnea 73%
●Pleuritic pain 66%
●Cough 37%
●Orthopnea 28%
●Calf or thigh pain and/or swelling 44%
●Wheezing 21%
●Hemoptysis 13%
Stein PD et al Chest. 1991;100(3):598.
Symptoms of PE

5. ●Leg findings 47%
Calf or thigh swelling, erythema, edema, tenderness, palpable cords
●Tachycardia 24%
●Rales 18%
●Decreased breath sounds 17%
●JVD 14%
●Fever  mimicking pneumonia 3%
Stein PD et al Chest. 1991;100(3):598.
Signs of PE

6. Well’s Criteria
• Sign of or Hx of DVT 3 Points
• PE your number one thought? 3 Points
• Tachycardia 1.5 Points
• Immobilization 1 Points
• Hemoptysis 1 Points
• Cancer 1 Points

7. • Score >6.0 — High
– Probability 59%
• Score 2.0 to 6.0 — Moderate
– Probability 29%
• Score <2.0 — Low
– Probability 15%
Stein PD et al Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
Well’s Criteria

8. PERC
RulesPulmonary Embolism Rule Out Criteria
<50?

10. PERC Rules
• Vital Signs (normal)
• Virchow’s Triad
• Hemoptysis
• Age < 50
• DVT?
<50

11. -

12. Cochrane Data
Regarding D. Dimers
• Limited evidence
• Few false-negatives
• Very high levels of false-positive
• This makes the test useful as a rule-out test
but means that a positive result requires
diagnostic imaging

13. Authors’ Conclusions:
• A negative D-dimer test is valuable to rule out
PE with a low PTP.
• Evidence from one study suggests that this
test may have less utility in older populations,
but no empirical evidence was available to
support an increase in the diagnostic
threshold of interpretation of D-dimer results
for those over the age of 65 years.

14. Chest or Pulmonary
Symptoms?
• Document on your charts:
100% of the time!!!
• 1) Arterial risk factors
• 2) Venous risk factors - Virchow’s
Triad
• 3) Symmetrical legs - “No Homan’s
Sign”