1. Pulmonary Embolism 101
Alex Rankin, MD

2. Learning Objectives
Better understanding of diagnosis and management of acute PE
Recognize acute PE
Learn how to Test
Learn how to Treat

3. Take Home Points PE can present as anything
Use Wells +/- PERC +/- Ddimer
Consider Age Adjusted Ddimer
Be cautious in your imaging
Be cautious in your treatment

4. Definition/ What We’ll Cover
PE= obstruction of Pulmonary Artery/branch by embolism originating elsewhere
Emboli: Air, Fat, Tumor, Thrombus
Subtypes: Acute, Subacute (days/weeks), Chronic
Presentation: Hemodynamically Stable or Unstable
Won’t cover: Pregnancy, Malignancy, VTE prophylaxis

5. CasePresentation Nurse calls 3am Cross Cover
65 y/o female with chest pain
Hospital day #5 for gallstone pancreatitis, slow to progress with diet.
Nonsmoker, no cardiac hx, no DM, HTN, no FMHx CAD
You astutely list Pulmonary Embolism as possible Differential Diagnosis
Why did you think that?
Now what do you do?

6. Clinical Presentation of PE
Anything!
Most Common:
Dyspnea
Pleuritic Chest Pain
Cough (hemoptysis less common)

7. Clinical Presentation of PE
Anything! - Take away Point #1
Most Common:
Dyspnea
Pleuritic Chest Pain
Cough (hemoptysis less common)

8. Workup of PE Assess clinical stability CXR, EKG Labs:
CBC, BMP, LFTs, INR, ABG

9. Classic Imaging Findings
Hamptons Hump
An anterior-posterior chest radiograph of a patient with suspected pulmonary embolus. Image A shows a wedge-shaped defect in the lateral segment of the middle lobe (arrow). Image B is a CT scan through the mid chest and shows the corresponding wedge-shaped defect (arrowhead) and thrombus in the pulmonary arteries subtending the middle lobe (arrows).

10. Classic Imaging Findings
Westermark Sign
A magnified A-P view of the left lung (A) shows a region of oligemia in the left lower chest (asterisk) in a patient with occlusive pulmonary embolism. Image B is a further magnification showing normal vasculature in the upper and lower lung regions but oligemia in the middle section (asterisk). The CT scan (C) shows a large saddle embolus of the left main pulmonary artery (arrow)

11. Classic EKG Findings Sinus Tachycardia (most common)
RV Strain (T wave inversions V1-4, inferior leads)
RBBB
RAD
Nonspecific ST/T changes
SI, QIII, TIII (only 10% of pts with PE)

12. https://lifeinthefastlane.com/ecg-library/pulmonary-embolism/

14. How to Test for PE 1. Start with a Clinical Decision Support tool
CDS has higher specificity for excluding PE over Clinician Gestalt when used with DDimer
Ann Intern Med Oct 4;155(7):

15. Wells Score
PULM%2F8261&rank=3~150&source=see_link&search=pulmonary%20embolism

16. Wells Score Low Probability--Use PERC Score
Low Prob + PERC (-): Sensitivity 97.4%, Specificity 21.9%, False Neg rate 1.0%
J Thromb Haemost 2008; 6: 772–80.

17. Wells Score Low Probability—Use PERC Score
--If ALL negative, no further testing indicated
--If ANY positive, get Ddimer  Imaging if Positive
PULM%2F94941&source=outline_link&search=pulmonary%20embolism

18. Wells Score Summary Low Prob (<2)
Use PERC
Intermediate Probability (Wells 2-6)
Get Ddimer  Imaging if Positive
High Probability (>6)
Proceed straight to imaging

19. Wells Score Summary
Take Away #2
Use Wells Score
+/- PERC
+/- Ddimer

20. Our Patient Wells score 4.5 Our pt: Moderate Probability
HR >100 1.0
No other Dx more likely than PE3.0
Our pt: Moderate Probability
Our pt: DDimer 680
Positive, but is it really positive?

21. Validated AgeX10 as Ddimer cut off for pts >50 y/o
Age Adjusted Ddimer
Prospective, non-randomized
Validated AgeX10 as Ddimer cut off for pts >50 y/o
JAMA. 2014;311(11): doi: /jama

22. Age-adjusted Ddimer increases specificity while preserving sensitivity
BMJ 2013;346:f2492 doi: /bmj.f2492 (Published 3 May 2013)

23. Back to our Patient Ddimer 680 Age: 65 Yes—this is positive
Take Home #3: Consider Age Adjusted Ddimer
Now what?

24. Take Away #3: Be cautious in your imaging
Imaging studies
CT Pulmonary Angiogram
Need good kidneys
Need to be stable for scan
Ventilation/Perfusion Scan
Need clear lungs
Usually not stat study
Bilateral lower extremity duplex ultrasound
Echocardiogram?
Take Away #3: Be cautious in your imaging

25. Our Patient
Arrowheads: Intra luminal thrombi in right pulmonary artery branches
Now what?

26. Acute PE Treatment Generally need admission
PESI Score (30 day Mortality)
Assess Bleeding risk
Rambam Maimonides Med J Oct; 5(4): e0037.

27. RIETE Study: Major Bleeding

28. RIETE Study: Major Bleeding
0 points: 0.3% bleeding risk
1-4 points: 2.6%
>4 points: 7.3%

29. RIETE Study: Fatal Bleeding
Nieto, José Antonio et al. Thrombosis Research , Volume 132 , Issue 2 ,

30. RIETE Study: Fatal Bleeding

31. RIETE Study: Fatal Bleeding
<1.5 points: 0.10% bleeding risk
1.5-4 points: 0.72%
>4 points: 1.44%

32. Take Away #4: Be cautious in your treatment
Acute PE Treatment
Anticoagulation
HeparinWarfarin
Need to be inpatient for entire bridge
Can stop quickly and reverse effect
Enoxaparin Warfarin or lifetime
Need to have good kidneys
Direct Oral Anticoagulant?
Need to have insurance
Need to be compliant
IVC filter/Embolectomy/tPA/etc
Take Away #4: Be cautious in your treatment

33. Our patient
Improved, Satisfied with her care, discharged home 5 days later. Anticoagulation clinic plans bridge for interval cholecystectomy
Take Home Points
PE can present as anything
Use Wells +/- PERC +/- Ddimer
Consider Age Adjusted Ddimer
Be cautious in your imaging
Be cautious in your treatment