Breathe Easy: Spotting Pulmonary Embolism

-Case-

A 45-year-old male with no past medical history comes into your ED mentioning that he has been feeling “off” all week. He has felt short of breath climbing the stairs and has been battling nagging chest discomfort that gets worse every time he takes a deep breath. Lately, he has been “glued to his desk for hours” working on reports for his job and feels like the back of his right calf has been hurting because of it. Vital signs show a heart rate of 110 bpm and an oxygen saturation of 94% on room air.

Uh-oh; an otherwise healthy guy not able to breathe well? What are some “can’t miss” pulmonary diagnoses common to the ED?

-Evaluation-

If you are thinking pulmonary embolism, you’re on the right track! Let’s dive into this patient’s situation.

For starters, how does PE present? The #1 symptom is shortness of breath. This, along with pleuritic chest pain – particularly a sharp, stabbing pain – should prompt worry for this pathology. Additionally, tachycardia, hypoxia, and hemoptysis should only further cement your concerns for PE. Lastly, syncope/shock could indicate a massive PE. Don’t ignore these signs and symptoms!

What makes someone at risk for PE? Here, Virchow’s triad is your roadmap:

  1. Stasis: DVT, prolonged immobility (desk jobs, recent flights, Netflix marathons)
  2. Hypercoagulability: cancer, pregnancy, OCP use, or inherited clotting disorders
  3. Endothelial Injury: recent surgery, trauma, or smoking

Okay, now the alarm bells for PE are sounding. How do we work to diagnose it?

  • D-dimer: In patients with a low Wells score, a normal D-dimer essentially rules out PE. On the flip side – a high D-dimer? Time to escalate.
  • CT Pulmonary Angiography (CTPA): The gold standard for PE evaluation. This is the next step in patients with a positive dimer. Alternatively, in higher-risk patients (ie., some moderate and all high Wells scores), we skip right to this step instead of waiting for a D-dimer!
  • ECG and CXR: will likely be normal in patients with PE, but don’t skip them! They can help rule out other causes for our patient’s symptoms. Despite the classic “SI QIII TIII” pattern people often talk about with pulmonary emboli, the most common EKG presentation in PE is actually sinus tach and T wave inversions!

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-Management-

You’ve nailed the PE diagnosis. Here’s our next plays:

  • Anticoagulation: best option for mortality reduction in stable PE patients. First-line medications are DOACs (like apixaban or rivaroxaban), but LMW is a great option for those who can’t tolerate PO. Typically, we opt for 3-6 months of AC prior to re-evaluation, but certain risk factors can also dictate the duration.
  • Thrombolysis or Thrombectomy: for our unstable patients, we can’t just wait for anticoagulation to work its magic! Consider thrombolysis (such as tPA) for persistent hypotension and/or shock (these become synonymous with massive PE).
    • Unfortunately, there are some contraindications for thrombolytics. This includes a known or prior intracranial neoplasm or bleed, < 2 months since intracranial trauma/injury/surgery, and prior ischemic CVA within the last 3 months.
  • Supportive Measures: don’t forget to do the little things while we prep the big guns! Give supplemental oxygen if your patient is hypoxic and, in some cases, sparing amounts of IV fluids can help with our hypotension.

-Fast Facts-

  • Remember the “big 3” – shortness of breath, chest pain, tachycardia should always prompt some level of concern for a PE; bonus points for hypoxia or hemoptysis
  • Immobility, cancer, hormonal meds, a recent surgery are all closely linked to PE
  • DVTs (think unilateral calf/leg swelling, localized lower extremity tenderness, edema) can progress to PE! In patients you are worried about PE, DVT symptoms (especially those not on AC) are much more concerning for PE
  • Wells Score is your best friend when considering PE and its evaluation! Use it to risk stratify and guide your next steps for diagnosis
  • Anticoagulation is great for stable patients; thrombolytics is the mainstay for unstable ones

For suspected PE, keep your Well’s score handy, rely on your team, and remember: trust your gut. It’s much better to have a lengthy but negative PE workup than not fully evaluate for one in a patient that needs it!

Want to read more about this topic? Click ✨here✨to read our in-depth study guide!

Cheers,

Tamir Zitelny, MD

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