Pulmonary embolism

Primary care management
How should I manage a person with suspected pulmonary embolism?

Arrange immediate admission for people with suspected pulmonary embolism:

If they are severely ill with any of the following features:

Altered level of consciousness.

Systolic BP of less than 90 mm Hg.

Heart rate of more than 130 beats per minute.

Respiratory rate of more than 25 breaths per minute.

Oxygen saturation of less than 91%.

Temperature of less than 35°C.

If they are pregnant.

For all other people, assess the two-level PE Wells score to estimate the clinical probability of PE.

Clinical features of deep vein thrombosis (minimum of leg swelling and pain with palpation of the deep veins) — 3 points.

Heart rate greater than 100 beats per minute — 1.5 points.

Immobilization for more than 3 days or surgery in the previous 4 weeks — 1.5 points.

Previous deep vein thrombosis or pulmonary embolism — 1.5 points.

Haemoptysis — 1 point.

Cancer (receiving treatment, treated in the last 6 months, or palliative) — 1 point.

An alternative diagnosis is less likely than pulmonary embolism — 3 points.
Alternative conditions to consider include:

Respiratory conditions such as pneumothorax, pneumonia, acute exacerbation of chronic lung disease.

Cardiac causes such as acute coronary syndrome, acute congestive heart failure, dissecting or rupturing aortic aneurysm, pericarditis.

Musculoskeletal chest pain. Note that chest pain with chest wall palpation occurs in up to 20% of people with confirmed PE.

Gastro-oesophageal reflux disease.

Any cause for collapse such as vasovagal syncope, orthostatic (postural) hypotension, cardiac arrhythmias, seizures, cerebrovascular disorders.

For people with a Wells score of more than 4 points (PE likely):

Either, arrange hospital admission for an immediate computed tomography pulmonary angiogram (CTPA).

Or, if there will be a delay in the person receiving a CTPA, give immediate interim low molecular weight heparin or fondaparinux and arrange hospital admission.

For people with a Wells score of 4 points or less (PE unlikely), arrange a D-dimer test:

If the test is positive, either arrange admission to hospital for an immediate CTPA or, if a CTPA cannot be carried out immediately, give immediate low molecular weight heparin or fondaparinux and arrange hospital admission.

If the test is negative consider an alternative diagnosis.

FOR MANAGEMENT IN HOSPITAL INCLUDING TREATMENT – REQUEST AUTHOR.

G Mohan.