Symptoms occur with at least 20-30% occlusion of vasculature
Gestalt based on clinician’s training, experience, and judgement PIOPED study (Prospective Investigation Of Pulmonary Embolism Diagnosis) was first to study gestalt in diagnosis (JAMA 1990) Low risk 0-19%, Intermediate 20-79%, high 80-100% PE Dx 9%, 30%, 70%
0-2 = PE unlikely 3-7 = PE likely
If patient is low-risk by gestalt (<15% chance of PE within next month) & PERC negative, there is <2% chance of clinically diagnosed VTE PERC provides one set of criteria to rule out PE (ACEP Level B recommendation)
False-positives = age >70, pregnancy, active malignancy, recent surgery, liver disease, RA, infections, trauma False-negatives = Coumadin use, symptoms >5days, small clots or infarction, isolated calf vein thrombosis
ACEP Level A – low pre-test probablity + negative dimer (ELISA, turbidometric) can rule out PE Level C – intermediate pre-test probablity + negative dimer MAY be used to rule out PE
Patient needs 20 ga peripheral IV or larger Radiation = 10-20 mSv (increases risk of CA to 1:500 lifetime risk) ACEP Level B – low risk or PE unlikely (Wells <4), CTPA can exclude PE Level C – intermediate risk (consider additional testing); high risk (must do additional testing)
BNP is one marker that gives a good view of how the patient will look in 6 months (BNP <900 is good) Thrombolysis is only useful for those who are at high risk for dying from PE More study needs to be done for thrombolysis in normotensive patients with RV dysfunction/elevated troponin Currently PEITHO study (PE Thrombolysis Study) Peitho = goddess of persuasion, charming speech, & seduction (study is sponsored by manufacturer of the lytic agent used)
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