1. EM. R1 박정숙

2. Purpose
Formulate comprehensive recommendations for the diagnostic approach to patients with suspected pulmonary embolism, based on randomized trials.

3. Methods
Based on results of Prospective Investigation of Pulmonay Embolism Diagnosis II
(PIOPED II)
Outcome study

4. Diagnostic test Clinical probability of pulmonary embolism
Condition of the patient
Availability of diagnostic test
Risks of iodinated contrast material
Radiation exposure
cost

5. D-dimer assay

9. Allergy to iodinated contrast material
D-dimer with clinical assessment
Treated with steroids before the CT imaging
Venous ultrasound and pulmonary scintigraphy
Serial venous ultrasound and gadoliniun-enhanced cT angiography are option

10. Impaired renal function
D-dimer with clinical assessment
Venous ultrasound
Pulmonary scintigraphy
Serial venous ultrasound is option

11. Womans reproductive age
D-dimer rapid ELISA
Venous ultrasound
Pulmonary scintigraphy
(minimized breast radiation)
CT angiogram with venous ultrasoud is alternative
CT venogram: start at the acetabulin to reduce gonadal irradiation

12. Radiation exposure

13. Pregnant patients D-dimer
Venous ultrasound before imaging test with ionizing radiation (13%~15%)
Pulmonary scintigraphy
CT angiogram
->Ventilation/perfusion scans are rcommended

14. Patients in Extremis Bedside echocardiography and lge ultrasonogray
(RV enlargement or poor RV function)
Venous ultrasound
Portable perfusion scan
Transfer to an interventional catheterization laboratory

15. Conclusion
The sequence for diagnostic test in patients with suspected pulmonary embolism depends on the clinical circumstaces

16. Conclusion
Negative D-dimer with low or moderate probability clinical assessment can safely exclude pulmonary embolism
Not excluded, CT angiography/CT venography is recommend
Further evaluation depends on clinical judgement