Pulmonology Book

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Pulmonary Embolism High Probability Evaluation

Aka: Pulmonary Embolism High Probability Evaluation, PE High Probability Evaluation, High PE Probability, High Clinical Suspicion for Pulmonary Embolism
  1. See Also
    1. Pulmonary Embolism
    2. Pulmonary Embolism Diagnosis
    3. Pulmonary Embolism Low Probability Evaluation
    4. Pulmonary Embolism Moderate Probability Evaluation
    5. Pulmonary Embolism Rule-Out Criteria (PERC Rule)
    6. Pulmonary Embolism Pretest Probability (Wells Clinical Prediction Rule for PE)
    7. Pulmonary Embolism Management
  2. 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
  3. Evaluation: Step 1 - 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. Jump to step 2 below
    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 2 below
      4. High Probability V/Q Scan
        1. Treat with Pulmonary Embolism Management
  4. Evaluation: Step 2 - Obtain Lower Extremity Compression Ultrasound
    1. Negative Compression Ultrasound
      1. Positive D-Dimer
        1. Jump to step 3 below OR
        2. Treat empirically as VTE and repeat the Ultrasound in 1 week
      2. Negative D-Dimer
        1. Consider alternative diagnosis
    2. Positive Compression Ultrasound
      1. Treat with Pulmonary Embolism Management
  5. Evaluation: Step 3 - Obtain pulmonary angiogram
    1. Pulmonary angiogram suggestive for PE (Positive)
      1. Treat with Pulmonary Embolism Management
    2. Pulmonary angiogram not suggestive for PE (Negative)
      1. No further evaluation needed
      2. Evaluate for alternative diagnosis
  6. References
    1. Ramzi (2004) Am Fam Physician 69:2829-36 [PubMed]
    2. Wells (1998) Ann Intern Med 129(12): 997-1005 [PubMed]
    3. Wilbur (2012) Am Fam Physician 86(10):913-9 [PubMed]

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