Pulmonary embolism

Last reviewed: 1 Nov 2022
Last updated: 25 Aug 2022

Summary

Definition

History and exam

Key diagnostic factors

  • chest pain
  • dyspnea
  • tachypnea
  • presyncope or syncope
  • hypotension (systolic BP <90 mmHg)
More key diagnostic factors

Other diagnostic factors

  • feeling of apprehension
  • cough
  • tachycardia
  • fever
  • unilateral swelling/tenderness of calf
  • hemoptysis
  • elevated jugular venous pressure
  • sternal heave
  • accentuated pulmonary component of S2
Other diagnostic factors

Risk factors

  • diagnosis of deep vein thrombosis
  • major surgery within the preceding 3 months
  • medical hospitalization within the preceding 2 months
  • active cancer
  • previous venous thromboembolic event
  • recent trauma or fracture
  • increasing age
  • pregnancy and postpartum
  • paralysis of the lower extremities
  • factor V Leiden mutation
  • prothrombin G20210A mutation
  • protein C and protein S deficiency
  • antithrombin deficiency
  • antiphospholipid antibody syndrome
  • medical comorbidity
  • use of specific drugs
  • obesity (BMI ≥29 kg/m²)
  • cigarette smoking
  • recent long-distance air travel
  • family history of venous thromboembolism
  • central venous catheterization
More risk factors

Diagnostic investigations

1st investigations to order

  • Wells criteria/Geneva score
  • multiple-detector computed tomographic pulmonary angiography (CTPA)
  • ventilation-perfusion (V/Q) scan
  • coagulation studies
  • BUN and creatinine, hepatic function tests
  • CBC
  • Pulmonary Embolism Rule-Out Criteria (PERC)
  • D-dimer test
More 1st investigations to order

Investigations to consider

  • chest x-ray
  • magnetic resonance (MR) angiography
  • pulmonary angiography
  • electrocardiography (ECG)
  • arterial blood gases (ABG)
  • thrombophilia screen
  • ultrasonography
  • YEARS criteria
  • troponin
More investigations to consider

Treatment algorithm

ACUTE

high risk (massive) PE or high clinical probability of PE with shock or hypotension (i.e., systolic BP <90 mmHg), no contraindication to anticoagulation or thrombolysis

high risk or intermediate-high risk, contraindication to anticoagulation or thrombolysis

intermediate-high risk PESI/sPESI score, no contraindication to anticoagulation or thrombolysis

intermediate-low risk or low risk PESI/sPESI score, no contraindication to anticoagulation

intermediate-low risk or low risk PESI/sPESI score, contraindication to anticoagulation

ONGOING

confirmed PE: no underlying malignancy, nonpregnant, no contraindication to anticoagulation

confirmed PE: malignancy, no contraindication to anticoagulation

confirmed PE: pregnant, no contraindication to anticoagulation

confirmed PE: severe renal impairment, no contraindication to anticoagulation

confirmed PE: hepatic impairment and coagulopathy, no contraindication to anticoagulation

confirmed PE: recurrent PE

Contributors

Authors

Scott Stevens, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

Professor of Medicine

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SS declares that he has no competing interests.

Scott C. Woller, MD

Director

Thrombosis Clinic

Intermountain Medical Center

Murray

Professor

Department of Medicine

Intermountain Healthcare and University of Utah

Salt Lake City

UT

Disclosures

SCW declares that he has no competing interests.

Gabriel V. Fontaine, PharmD, MBA, BCPS

Clinical Pharmacy Manager

Critical Care and Emergency Medicine

Advanced Clinical Pharmacist

Neuroscience Critical Care

Intermountain Medical Center

Murray

UT

Disclosures

GVF has received consulting fees and speaking honoraria from Alexion Pharmaceuticals.

Acknowledgements

Dr Scott M. Stevens, Dr Scott C. Woller, and Dr Gabriel V. Fontaine would like to gratefully acknowledge Drs Geno Merli, Luis H. Eraso, Taki Galanis, Geoffrey Ouma, Miguel Angel de Gregorio, Alicia Laborda, and Seth W. Clemens, previous contributors to this topic.

Disclosures

GM has received grants or research support from BMS, J&J, Sanofi-Aventis, Portola, and Janssen; he has served as a Scientific Consultant for BMS, J&J, and Sanofi-Aventis. LHE, TG, GO, MAG, AL, and SWC declare that they have no competing interests.

Peer reviewers

Keith Wille, MD, MSPH

Associate Professor of Medicine

University of Alabama at Birmingham

Birmingham

AL

Disclosures

KW declares that he has no competing interests.

John R. Charpie, MD, PhD

Associate Professor of Pediatrics

Medical Director

Pediatric Cardiothoracic Intensive Care Unit

University of Michigan Congenital Heart Center

C.S. Mott Children's Hospital

Ann Arbor

MI

Disclosures

JRC declares that he has no competing interests.

Sanjeev Wasson, MD

Advanced Clinical Fellow

Cleveland Clinic Foundation

Cleveland

OH

Disclosures

SW declares that he has no competing interests.

David Jimenez, MD, PhD

Respiratory Physician and Associate Professor

Ramón y Cajal Hospital and Alcalá de Henares University

Respiratory Department and Medicine Department

Madrid

Spain

Disclosures

DJ has received consulting fees from Boehringer Ingelheim, Bayer, Leo-Pharm, and Rovi, and lecture fees from Sanofi Aventis.

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