Pulmonary Embolism (Suspected-Adult)

Evaluation and Management of Adult Emergency Department Patients with Suspected Pulmonary Embolism (January 2011)

Complete Clinical Policy on Suspected Pulmonary Embolism (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments or emergency department-based observation centers.

Inclusion Criteria. This guideline is intended for adult patients presenting to the emergency department with suspected pulmonary embolism.

Exclusion Criteria. This guideline is not intended to address the care of patients with pulmonary embolism in the presence of cardiac arrest or pregnancy, patients with absence of symptoms suggestive of pulmonary embolism, or pediatric patients.


Critical Questions


1. Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible pulmonary embolism?
 

  • Level A recommendations. None specified.
  •  Level B recommendations. Either objective criteria or gestalt clinical assessment can be used to risk stratify patients with suspected pulmonary embolism. There is insufficient evidence to support the preferential use of one method over another.
  • Level C recommendations. None specified.


2. What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected pulmonary embolism?
 

  • Level A recommendations. None specified.
  • Level B recommendations. In patients with a low pretest probability for suspected pulmonary embolism, consider using the PERC to exclude the diagnosis based on historical and physical examination data alone.
  • Level C recommendations. None specified.


3. What is the role of quantitative D-dimer testing in the exclusion of pulmonary embolism?
 

  • Level A recommendations. In patients with a low pretest probability for pulmonary embolism, a negative quantitative D-dimer assay* result can be used to exclude pulmonary embolism.
  • Level B recommendations. None specified.
  • Level C recommendations. In patients with an intermediate pretest probability for pulmonary embolism, a negative quantitative D-dimer assay* result may be used to exclude pulmonary embolism. 

*High sensitivity (eg, turbidimetric, ELISA).


4. What is the role of the computed tomography (CT) pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of pulmonary embolism?

 

  • Level A recommendations. None specified.
  •  Level B recommendations. For patients with a low or pulmonary embolism unlikely (Wells score <4) pretest probability for pulmonary embolism who require additional diagnostic testing (eg, positive D-dimer result, or highly sensitive D-dimer test not available), a negative, multidetector CT pulmonary angiogram alone can be used to exclude pulmonary embolism. 
  •  Level C recommendations
  • (1) For patients with an intermediate pretest probability for pulmonary embolism and a negative CT pulmonary angiogram result in whom a clinical concern for pulmonary embolism still exists and CT venogram has not already been performed, consider additional diagnostic testing (eg, D-dimer,* lower extremity imaging, ventilation-perfusion (VQ) scanning, traditional pulmonary arteriography) prior to exclusion of venous thromboembolism disease. 
  • (2) For patients with a high pretest probability for  pulmonary embolism and a negative CT angiogram result, and CT venogram has not already been performed, perform additional diagnostic testing (eg, D-dimer,* lower extremity imaging, VQ scanning, traditional pulmonary arteriography) prior to exclusion of venous thromboembolism disease. 

 *A negative, highly sensitive, quantitative D-dimer result in combination with a negative multidetector CT pulmonary angiogram result theoretically provides a posttest probability of venous thromboembolism disease less than 1%.


5. What is the role of venous imaging in the evaluation of patients with suspected pulmonary embolism? 

  • Level A recommendations. None specified.
  • Level B recommendations. When a decision is made to perform venous ultrasound as the initial imaging modality,* a positive finding in a patient with symptoms consistent with pulmonary embolism can be considered evidence for diagnosis of venous thromboembolism disease and may preclude the need for additional diagnostic imaging in the emergency department.
    *Examples of situations in which a venous ultrasound may be considered as initial imaging may include patients with obvious signs of deep venous thrombosis for whom venous ultrasound is readily available, patients with relative contraindications for computed tomography (CT) scan (eg, borderline renal insufficiency, CT contrast agent allergy), and pregnant patients. 
  • Level C recommendations
  • (1) For patients with an intermediate pretest probability for pulmonary embolism and a negative CT angiogram result, for whom a clinical concern for pulmonary embolism still exists and CT venogram has not already been performed, consider lower extremity venous ultrasound as an additional test to exclude venous thromboembolism disease (see question 4).
  • (2) In patients with a high pretest probability for pulmonary embolism and a negative CT angiogram result, and CT venogram has not already been performed, perform additional testing to exclude venous thromboembolism disease (see question 4). As one of these additional tests, consider lower extremity venous ultrasound to exclude venous thromboembolism disease (see question 4).
     

 6. What are the indications for thrombolytic therapy in patients with pulmonary embolism?  

  • Level A recommendations. None specified.
  • Level B recommendations. Administer thrombolytic therapy in hemodynamically unstable patients 
    with confirmed pulmonary embolism for whom the benefits of treatment outweigh the risks of life-threatening bleeding complications.*
    * In centers with the capability for surgical or mechanical thrombectomy, procedural intervention may be used as an alternative therapy. 
  • Level C recommendations
  • (1) Consider thrombolytic therapy in hemodynamically unstable patients with a high clinical suspicion for pulmonary embolism for whom the diagnosis of pulmonary embolism cannot be confirmed in a timely manner.
  • (2) At this time, there is insufficient evidence to make any recommendations regarding use of thrombolytics in any subgroup of hemodynamically stable patients. Thrombolytics have been demonstrated to result in faster improvements in right ventricular function and pulmonary perfusion, but these benefits have not translated to improvements in mortality.

Purpose of ACEP’s Clinical Policies

 Clinical Findings and Strength of Recommendations
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