Pulmonary Embolism

PE’s (or Pulmonary Emboli) are a key part of Emergency Care, something that many of us will consider as a differential diagnosis multiple times of a daily basis, in a similar way to acute coronary syndrome, so we need to be absolute experts on the topic!

A PE normally occurs when a Deep Vein Thrombosis shoots off to the pulmonary arterial tree, occurring in 60-120 per 100,000 of the population per year

The inhospital mortality is 14% and the 90 day mortality is around 20%. But this is proportional to its size, and risk stratifying PE’s once we’ve got the diagnosis is really important.

PE is a real diagnostic challenge and less than 1 in 10 who are investigated for a PE end up with the diagnosis, so knowing the risk factors, associated features and thresholds for work up are really important.

There are some key concepts in risk stratification and particularly in test thresholds that we’ll cover in this episode that are applicable to all of our practice…..we’re excited! Getting these right helps us to avoid missing the diagnosis and equally importantly ensure we aren’t ‘over testing’ & ‘over diagnosing’ because investigation and treatment for a PE isn’t without it’s own risks.

In the episode we’ll talk in depth about factors associated with presentation, risk factors, investigations and finally onto treatments, covering the whole spectrum from low risk PE’s up to those with massive PE’s and cardiac arrest. The evidence base behind the work up and treatments is truly fascinating and we hope you find this episode as eye-opening as we did to prepare for!

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

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References

NICE CKS Summary; Pulmonary Embolism. 2022

Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. Righini. JAMA. 2014

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. Schouten. BMJ. 2013

An Age-Adjusted D-dimer Threshold for Emergency Department Patients With Suspected Pulmonary Embolus: Accuracy and Clinical Implications. Sharp. Ann Emery Med. 2016

Multidetector Computed Tomography for Acute Pulmonary Embolism. Stein. NEJM. 2006

Lung Ventilation Perfusion Scan (VQ Scan). Mirza. StatsPearls. 2023

Accuracy of PE rule-out strategies in pregnancy: secondary analysis of the DiPEP study prospective cohort. Goodacre. EMJ. 2020

Fibrinolysis for patients with intermediate-risk pulmonary embolism. Meyer. NEJM. 2014

Perinatal Mortality Surveillance: UK perinatal deaths of babies born in 2021. MBRRACE-UK

Thrombolytics in Cardiac Arrest from Pulmonary Embolism: A Systematic Review and Meta Analysis. J. Feltes. Journal Intensive Care Medicine. 2024

Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Bottiger. New England Journal of Medicine. 2008

EMCRIT; IBCC PE

Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Marti. Eur Heart J. 2015

Thrombolytic therapy for pulmonary embolism. Cochrane Review 2021

Streptokinase and Heparin versus Heparin Alone in MassivePulmonary Embolism: A Randomized Controlled Trial.Jerjes-Sanchez C. J Thromb Thrombolysis. 1995

LITFL; Pulmonary Embolism

Acute Pulmonary Embolism. Vyas. StatPearls. 2024

Classification and Stratification of Pulmonary Embolisms. Int J Angiol. 2022 

2019 Guidelines on Acute Pulmonary Embolism (Diagnosis and Management of). ESC. 2019

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of

Pulmonary Embolism; Radiopedia

Pulmonary embolism: update on management and controversies. Duffett. BMJ. 2020

Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. Kline. J Thromb Haemost. 2004

Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. Kline. J Thromb Haemost. 2008

PERC Rule for Pulmonary Embolism; MD Calc

Guidelines For The Initial Outpatient Management of Pulmonary Embolism; BTS 2018

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016

Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. Schultz DJ.J Trauma. 2004

Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT) scanning. Ritchie G. Thorax. 2007

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