EM · Pulmonary embolism
Pulmonary embolism (acute, in the emergency department)
Also known as PE · Massive pulmonary embolism · Venous thromboembolism · Submassive PE
Acute pulmonary embolism — the PE–DVT continuum and the Virchow risk factors, the right-ventricular-afterload pathophysiology that kills in massive PE, the Wells and PERC risk-stratification tools, the workup (D-dimer, CTPA, V/Q, echo, ECG), the risk-tiered management (massive PE with shock to thrombolysis or embolectomy; submassive and low-risk to anticoagulation with a DOAC), the cautious-fluids-in-shock rule, and the pregnancy pathway. ACEM-primary, globally tagged.
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Red flags
- A pulmonary embolism with hypotension or shock is a massive (high-risk) PE — it needs reperfusion (thrombolysis or embolectomy), not anticoagulation alone
- A normal oxygen saturation or a normal ECG does NOT exclude a pulmonary embolism
- Large fluid boluses worsen the right ventricle in a massive PE — use small boluses and a vasopressor, and reperfusion
- A pulmonary embolism is a leading cause of pulseless-electrical-activity cardiac arrest — give thrombolysis during CPR if a PE is suspected
- A raised D-dimer is not diagnostic and a normal one only helps to rule out PE in a low-risk patient
Meet the patient
A 62-year-old man, ten days out from a total knee replacement, hits the floor of resus twenty minutes after sudden pleuritic chest pain and a syncope at home. He is grey, diaphoretic, RR 32, SpO₂ 88 per cent on 15 L, BP 84/50, sinus tachycardia at 128. The JVP is up to the jaw and the chest is clear. The registrar reaches for the litre bolus.[1][2]
Hold that hand. This is a massive pulmonary embolism, and the two questions that decide his next half-hour are the two that decide every PE: is he shocked? (then reperfusion, not fluids, and not a trip to the CT scanner) and what is the right ventricle doing? (bedside echo, then unblock it). Get those two right and the rest of the algorithm slots in behind them.[1][2]
References12ShowHide
- [1]Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria J Thromb Haemost, 2008.PMID 18318689
- [2]Ebner M, Sentler C, Harjola VP, et al. Outcome of patients with different clinical presentations of high-risk pulmonary embolism Eur Heart J Acute Cardiovasc Care, 2021.PMID 34125186
- [3]Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer Thromb Haemost, 2000.PMID 10744147
- [4]van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography JAMA, 2006.PMID 16403929
- [5]The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED) JAMA, 1990.PMID 2332918
- [6]Righini M, Van Es J, Den Exter PL, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study JAMA, 2014.PMID 24643601
- [7]Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism N Engl J Med, 2002.PMID 12374874
- [8]Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism N Engl J Med, 2014.PMID 24716681
- [9]Büller HR, Prins MH, Lensin AW, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism N Engl J Med, 2012.PMID 22449293
- [10]Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) Eur Heart J, 2020.PMID 31504429
- [11]Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism N Engl J Med, 2013.PMID 23808982
- [12]Kiser TH, Burnham EL, Clark B, et al. Half-Dose Versus Full-Dose Alteplase for Treatment of Pulmonary Embolism Crit Care Med, 2018.PMID 29979222