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

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