Pulmonary embolism resident survival guide: Difference between revisions

Pulmonary embolism Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Long term treatment
Do's

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Latest revision as of 19:38, 10 July 2014

For pulmonary embolism prevention resident survival guide click here.

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Pratik Bahekar, MBBS [3]; Chetan Lokhande, M.B.B.S [4]

Overview

Pulmonary embolism (PE) is the acute obstruction of the pulmonary artery or one of its branches by a thrombus, air, tumor, or fat. Most often, PE is due to a venous thrombus which has been dislodged from its site of formation in the deep veins of the lower extremities, a process referred to as venous thromboembolism. PE is a potentially lethal condition. The patient can present with a range of signs and symptoms; however, the typical presentation is characterized by dyspnea (78-81% of the cases), pleuritic chest pain (39-56% of the cases), and/or syncope (22-26% of the cases).^[1] The diagnostic approach of PE depends on whether the patient is a high-risk patient due to the presence of hypotension and/or shock or a non-high risk patient, as well as on the pre-test probability of this disease. While fibrinolytic therapy is the treatment of choice for patients with massive PE, patients with non-massive PE are treated with anticoagulation therapy.^[2]

Causes

Life Threatening Causes

Pulmonary embolism is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Blood clot (most common cause)
Air bubble
Fragment of a tumor
Fragment of fat (secondary to bone fracture)
Amniotic fluid

Classification

Massive Pulmonary Embolism

Massive pulmonary embolism falls under the category "high risk patients" in the European guidelines. High risk PE patients have a risk of PE-related early mortality of > 15%.^[3]
Massive PE is characterized by the presence of:

Sustained hypotension (systolic blood pressure <90 mm Hg) not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, that is either lasting for at least 15 minutes or necessitating the administration of inotropes

OR

Pulselessness

OR

Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock^[4]

Submassive Pulmonary Embolism

Submassive pulmonary embolism falls under the category "intermediate risk patients" in the European guidelines. Intermediate risk PE patients have a risk of PE-related early mortality ranging between 3 and 15%.^[3]
Submassive PE is characterized by:

Right ventricular dysfunction OR myocardial necrosis

AND

Absence of systemic hypotension (systolic blood pressure >90 mm Hg)^[4]^[5]

Right Ventricular Dysfunction

Right ventricular (RV) dysfunction is characterized by the presence of AT LEAST ONE of the following:^[4]^[5]

Echocardiography findings:
- RV dilation (ratio of apical 4-chamber RV diameter to left ventricle (LV) diameter > 0.9)
- RV systolic dysfunction
CT findings: RV dilation (ratio of 4-chamber RV diameter to LV diameter > 0.9)
BNP > 90 pg/mL
N-terminal pro-BNP >500 pg/mL
EKG findings:
- New complete or incomplete right bundle-branch block
- Anteroseptal ST elevation or ST depression
- Anteroseptal T-wave inversion

Myocardial Necrosis

Myocardial necrosisis defined as the presence of:^[4]^[5]

Elevation of troponin I (>0.4 ng/mL)

OR

Elevation of troponin T (>0.1 ng/mL)

Low-Risk Pulmonary Embolism

Low risk PE patients have a risk of PE-related early mortality of <1%.^[3] Low risk PE is characterized by the absence of hypotension, shock, RV dysfunction, and myocardial necrosis.^[4]

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.^[3]^[4]^[2]

Abbreviations: CT: Computed tomography; IV: Intravenous; IVC: Inferior vena cava; PE: Pulmonary embolism; PERC: PE Rule-Out Criteria; RV: Right ventricle; SC: Subcutaneous; VKA: Vitamin K antagonist

Step 1: Confirm PE

Identify cardinal findings that increase the pretest probability of PE
❑ Dyspnea
❑ Pleuritic chest pain
❑ Syncope
❑ Tachycardia
❑ Tachypnea

Does the patient who is suspected to have PE have hypotension or shock?

Yes

No

Suspected high-risk PE

Suspected non-high risk PE

❑ Administer parenteral anticoagulation
(in case there are no contraindications)
during the diagnostic workup

Is a CT available immediately?

What is the pretest probability of PE?

No

Yes

❑ Order Echocardiography

Does the patient have RV overload?

Low pretest probability

Intermediate pretest probability

High pretest probability
OR
PE is likely

❑ Administer parenteral anticoagulation
(in case there are no contraindications)
during the diagnostic workup

❑ Administer anticoagulation
(in case there are no contraindications)
during the diagnostic workup

No

Yes

❑ Order CT

❑ Order D-dimer

Positive

Negative

Positive

Negative

Is the patient unstable
OR
no other tests are available?

Is the patient stabilized
AND
CT is now available?

❑ Order CT

PE is excluded

❑ Order CT

Positive

Negative

Positive

Negative

PE is excluded

❑ Consider thrombolytic therapy
OR
❑ Embolectomy

❑ Order CT

PE is confirmed

PE is excluded

PE is confirmed

PE is excluded

PE is confirmed

PE is excluded

Positive for PE

Negative for PE

Click here for the initial treatment

PE is confirmed

PE is excluded

Click here for the initial treatment

Assessment of the Pretest Probability of PE

The assessment of the pretest probability of PE can be achieved through scoring systems. The most commonly used score is the Wells score. Other scores, such as Geneva score and PERC can also be used.

Wells Score

The Wells score is a simple, commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have pulmonary embolism.^[6]^[7]^[8]^[9]

Calculation of Wells Score

Pulmonary embolism Wells Score Calculator

Variable	Wells Score^[8]
Clinically suspected DVT (leg swelling, pain with palpation)	3.0
Alternative diagnosis is less likely than PE	3.0
Immobilization/surgery in previous four weeks	1.5
Previous history of DVT or PE	1.5
Tachycardia (heart rate more than 100 bpm)	1.5
Malignancy (treatment for within 6 months, palliative)	1.0
Hemoptysis	1.0

Interpretation of Wells Score

Wells Criteria

Shown below is the pretest probability of PE according to Wells criteria.^[8]^[9]^[10]

Score >6.0: High probability (Rate of PE: ~66.7%)
Score 2.0 to 6.0: Moderate probability (Rate of PE: ~20.5%)
Score <2.0: Low probability (Rate of PE: ~3.6%)

Modified Wells Criteria

Shown below is the pretest probability of PE according to the modified Wells Criteria.^[8]^[9]^[10]^[11]

Score > 4: PE likely (Rate of PE: ~40.7%)
Score 4 or less: PE unlikely (Rate of PE: ~7.8%)

Step 2: Initial Treatment

Assess the severity of pulmonary embolism

Massive PE
(also known as high-risk PE)
Cardiogenic shock
OR
Persistent hypotension (≤90mmHg)
OR
Drop of the blood pressure by ≥ 40mmHg for > 15 min^[12]
OR
Pulselessness
OR
Profound bradycardia (<40 bpm) with findings of shock^[4]

Submassive PE
(also know as intermediate-risk PE)
Right ventricular dysfunction
AND/OR
Myocardial injury (Troponin +)

Low-risk PE
No cardiogenic shock
AND
No hypotension
AND
No right ventricular dysfunction
AND
No myocardial injury (Troponin -)

Provide hemodynamic and respiratory support

❑ Begin high dose unfractionated heparin^[12]

❑ Bolus 10.000 U

❑ Continuous infusion of at least 1250 U/hour for a targeted aPTT of at least 80 s

❑ Administer rapidly 500-1000 mL of normal saline (caution with fluid overload)^[12]
❑ Have a low threshold for ionotropes (dopamine or dobutamine)^[12]

❑ Administer oxygen for hypoxemic patients^[12]

Is there any contraindication to fibrinolytic therapy?

Is there any contraindication for anticoagulation therapy?

NO

YES

NO

YES

NO

YES

❑ Discontinue unfractionated heparin
AND
❑ Begin fibrinolytic therapy

❑ Surgical pulmonary embolectomy
OR
❑ Percutaneous catheter embolectomy

❑ Anticoagulation therapy
AND
❑ Hospital admission

❑ IVC filter
AND
❑ Hospital admission

❑ Anticoagulation therapy
AND
❑ Early discharge/home treatment

❑ IVC filter
AND
❑ Early discharge/home treatment

Does the patient fail to improve
OR
Develop cardiogenic shock
OR
Develop hypotension?

Does the patient fail to improve
OR
Develop cardiogenic shock
OR
Develop hypotension (<90 mmHg)
OR
Develop respiratory distress (SaO2<95% with Borg score>8 or altered mental status)
OR
Have moderate to severe RV dysfunction (RV hypokinesis or estimated RVSP>40 mmHg)
OR
Have elevated biomarkers (troponin> upper limit of normal, BNP>100 pg/mL, or pro-BNP>900 pg/mL)?^[4]

YES

NO

YES

NO

❑ Surgical pulmonary embolectomy
OR
❑ Percutaneous catheter embolectomy

❑ Continue with the same treatment

Is there any contraindication for fibrinolytic therapy?

❑ Continue with the same treatment

NO

YES

❑ Hold anticoagulation and give thrombolytics

❑ Surgical pulmonary embolectomy
OR
❑ Percutaneous catheter embolectomy

Does the patient fail to improve?

YES

NO

❑ Surgical pulmonary embolectomy
OR
❑ Percutaneous catheter embolectomy

❑ Continue with the same treatment

Dosage of Fibrinolytic Therapy

Shown below is the dosage schedule for the thrombolytic agents:^[4]

Streptokinase (FDA-approved)
- Loading dose: 250 000 IU over 30 min
- Maintenance dose: 100 000 IU/h over 12–24 hr
- Accelerated regimen: 1.5 million IU over 2 hr
Urokinase (FDA-approved)
- Loading dose: 4400 IU/kg over 10 min
- Maintenance dose: 4400 IU/kg/h over 12–24 hr
- Accelerated regimen: 3 million IU over 2 hr
Recombinant tissue plasminogen activator (rtPA)^[13]
- Alteplase (FDA-approved): 10-mg IV bolus followed by 90 mg IV infusion over 2 hours
- Reteplase: 10-U IV bolus followed in 30 mins by another 10-U IV bolus
- Tenecteplase: 0.5-mg/kg IV bolus (max 50mg)

Contraindications to Fibrinolytic Therapy

Shown below is a table summarizing the absolute and relative contraindications to fibrinolytic therapy among pulmonary embolism patients.^[3]

Absolute contraindications	Relative contraindications
❑ Previous hemorrhagic stroke or stroke of unknown origin ❑ Ischemic stroke within the last 6 months ❑ Central nervous system tumor or damage ❑ Major trauma, head injury, or surgery within the last 3 weeks ❑ Gastrointestinal bleed within the last month ❑ Known bleeding	❑ Transient ischemic attack within the last 6 months ❑ Oral anticoagulant therapy intake ❑ Advanced liver disease ❑ Infective endocarditis ❑ Peptic ulcer disease that is currently active ❑ Pregnancy or within 1 week post partum ❑ Punctures that are non-compressible ❑ Traumatic resuscitation ❑ Systolic blood pressure >180 mmHg refractory to treatment

Choice of Initial Anticoagulation Therapy

Begin initial anticoagulation therapy in:
❑ Confirmed PE
OR
❑ High or intermediate probability of PE while awaiting the diagnostic tests

Is the patient high risk or non-high risk?

High risk

Non-high risk

❑ Administer IV unfractionated heparin

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR

❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients^[14]

❑ Adjust the dosages according to the aPTT

Does the patient have:
❑ High risk of bleeding
OR
❑ Severe renal failure?

Yes

No

❑ Administer unfractionated heparin:^[3]

IV injection

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR

❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients^[14]

❑ Adjust the dosages according to the aPTT
OR

SC injection

❑ 333 U/kg as bolus, followed by 250 U/kg^[14]

❑ Administer VKA as an overlap anticoagulation if VKA is planned for long term treatment

❑ Administer ONE of the following:

❑ SC low molecular weight heparin (1st line)

❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily

❑ Tinzaparin 175 U/kg once daily

❑ SC fondaparinux (1st line)

❑ 5 mg once daily (if body weight <50 kg)

❑ 7.5 mg once daily (if body weight <50-100 kg)

❑ 10 mg once daily (if body weight >100 kg)

❑ IV unfractionated heparin

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR

❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients^[14]

❑ Adjust the dosages according to the aPTT

❑ SC unfractionated heparin

❑ 333 U/kg as bolus, followed by 250 U/kg^[14]

❑ Administer VKA as an overlap anticoagulation if VKA is planned for long term treatment

Adjustment of Heparin Dosage According to aPTT

aPTT	Variation in the dosage^[3]
< 1.2 x control (<35 s)	Bolus: 80 U/kg Infusion rate: increase by 4 U/kg/h
1.2-1.5 x control (35-45 s)	Bolus: 40 U/kg Infusion rate: increase by 2 U/kg/h
1.5-2.3 x control (46-70 s)	Continue the same dosage
2.3-3.0 x control (71-90 s)	Infusion rate: decrease by 2 U/kg/h
> 3.0 x control (>90s)	Stop infusion for a period of 1 hour, then Infusion rate: decrease by 3 U/kg/h

Contraindications to Anticoagulation

Disorders predisposing to bleeding
Gastrointestinal bleeding
Genitourinary tract bleeding
Prior history of peptic ulcer disease
Severe thrombocytopenia
Surgery within the prior 14 days
Thrombotic stroke within the prior 14 days^[15]

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: DVT: Deep venous thrombosis; JVD: Jugular venous distention; P2: Second heart sound; RV: right ventricle; S3: Third heart sound ; S4: Fourth heart sound

Characterize the symptoms: ❑ Dyspnea (78–81%)^[16] ❑ Pleuritic chest pain (39–56%)^[16] ❑ Fainting (22–26%)^[16] ❑ Cough (20%)^[3] ❑ Substernal chest pain (12%)^[3] ❑ Hemoptysis (11%)^[3] ❑ Wheezing ❑ Cyanosis (11%)^[16] ❑ Fever (7%)^[16] ❑ Asymptomatic ❑ Findings suggestive of DVT (15%)^[3] ❑ Calf or thigh pain and swelling ❑ Edema, erythema, tenderness, or a palpable cord in the calf or thigh ❑ Symptoms suggestive of shock (in case of massive PE) ❑ Altered mental status ❑ Cold extremities ❑ Cyanosis ❑ Oliguria



Elicit a detailed history: ❑ Risk factors^[3]^[17] ❑ Chemotherapy ❑ Chronic heart failure ❑ Respiratory failure ❑ Hormone replacement therapy ❑ Cancer ❑ Oral contraceptive pills ❑ Stroke ❑ Pregnancy ❑ Postpartum ❑ Prior history of VTE ❑ Thrombophilia ❑ Advanced age ❑ Laparoscopic surgery ❑ Prepartum ❑ Obesity ❑ Varicose veins ❑ Triggers^[3]^[17] ❑ Bone fracture (hip or leg) ❑ Hip replacement surgery ❑ Knee replacement surgery ❑ Major general surgery ❑ Significant trauma ❑ Spinal cord injury ❑ Athroscopic knee surgery ❑ Central venous lines ❑ Chemotherapy ❑ Bed rest for more than 3 days ❑ Prolonged car or air travel ❑ Laparoscopic surgery ❑ Prepartum ❑ Previous episode of VTE ❑ Age ❑ Location ❑ Past medical history of diseases associated with hyperviscosity ❑ Atherosclerosis ❑ Collagen vascular disease ❑ Heart failure ❑ Myeloproliferative disease ❑ Nephrotic syndrome ❑ Autoimmune diseases ❑Polycythemia vera ❑ Hyperhomocysteinemia ❑ Paroxysmal nocturnal hemoglobinuria ❑ Waldenstrom macroglobulinemia ❑ Multiple myeloma ❑ History of thrombophilia ❑ Factor V Leiden mutation ❑ Prothrombin gene mutation G20210A ❑ Protein C or Protein S deficiency ❑ Antithrombin (AT) deficiency ❑ Antiphospholipid syndrome (APS) ❑ Abortion ❑ Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS) ❑ Drugs that may increase the risk of VTE ❑ Hydralazine ❑ Phenothiazine ❑ Procainamide ❑ Tamoxifen ❑ Bevacizumab ❑ Glucocorticoids ❑ Family history (suggestive of inherited thrombophilia) ❑ Deep vein thrombosis ❑ Pulmonary embolism ❑ Recurrent miscarriage ❑ Social history ❑ Heavy cigarette smoking (>25 cigarettes per day) ❑ Intravenous drug use (if injected directly in femoral vein) ❑ Alcohol



Examine the patient: Vital signs ❑ Blood pressure ❑ Blood pressure lower than baseline, suggestive of cardiogenic shock (associated with tachycardia and end organ hypoperfusion) ❑ Tachycardia (26%)^[3] ❑ Tachypnea (70%)^[3] ❑ Low grade fever Skin ❑ Lower extremity swelling, erythema, and/or tenderness suggestive of DVT ❑ Edema (suggestive of right heart failure) ❑ Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock) Heart ❑ Cardiac murmur ❑ Graham-Steell murmur (suggestive of pulmonary regurgitation) ❑ Accentuated P2 ❑ S3 or S4 gallop (suggestive of RV dysfunction) ❑ JVD (suggestive of right heart failure) Lungs ❑ Rales ❑ Crackles ❑ Pleural friction rub



Order tests: ❑ CBC ❑ Electrolytes ❑ ABG ❑ Hypoxemia ❑ Hypocapnea ❑ Respiratory alkalosis ❑ EKG ❑ Sinus tachycardia ❑ Stress on the right ventricle ❑ Right axis deviation ❑ Right bundle branch block ❑ S1Q3T3 ❑ Deep S in lead I ❑ Q wave in lead III ❑ Inverted T wave in lead III ❑ Chest X ray^[18] ❑ Atelectasis (most common) ❑ Fleishner sign: enlarged pulmonary artery ❑ Hampton hump: peripheral wedge-shaped density above the diaphragm that implies lung infarction ❑ Westermark's sign: vasoconstriction distal to the pulmonary embolus ❑ Pleural effusion ❑ Elevated diaphragm ❑ Enlarged hilum ❑ Normal (in 12%)

Long Term Treatment

The long term treatment of PE depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient. Among non cancer patients, the first line therapy for long term management of PE is vitamin K antagonists (VKA); whereas the first line treatment among cancer patients is low molecular weight heparin. If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the INR is ≥2 for at least 24 hours. Among patients on extended anticoagulation therapy, the risk vs benefits of the anticoagulation therapy should be assessed regularly (for example annually).^[2]

Is this the first episode of PE?

YES

NO

Is PE provoked?

What is the risk of bleeding?

Yes, transient reversible risk factor

Yes, cancer

No (unprovoked)

Low or moderate

High

Therapy for 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Extended therapy or until cancer is cured

❑ LMWH (first line)
OR
❑ VKA
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Therapy for ≥ 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Extended therapy

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Therapy for 3 months

❑ VKA (first line)
OR
❑ LMWH
OR
❑ Dabigatran
OR
❑ Rivaroxaban

Re-assess the risk of bleeding

Low or moderate

High

Extended therapy

Do not extend the therapy beyond the initial 3 months

Note that edoxaban^[19] has been evaluated for the treatment of VTE and is currently seeking approval for this indication.

Vitamin K Antagonist

Begin with 5 mg warfarin for 2 days followed by dosing based on the INR.
Start at the 1st or 2nd day of the initial parenteral therapy.
Target INR is 2-3.
Monitor INR monthly.
- If the INR is stable but there is one value 0.5 below or above the target range, continue the same dose and repeat INR within 1-2 weeks.
Avoid NSAIDs, COX2 selective NSAIDs and some antibiotics^[14]

Assessment of Risk of Bleeding

The risk factors of bleeding with anticoagulation therapy are:^[2]

Age > 75 years
Alcohol abuse
Anemia
Antiplatelet therapy
Cancer
Comorbidity and reduced functional capacity
Diabetes
Frequent falls
Liver failure
Metastatic cancer
Poor anticoagulant control
Previous bleeding
Prior stroke
Recent surgery
Renal failure
Thrombocytopenia

Shown below is a table summarizing the risk of bleed based on the number of risk factors. Note that, although the presence of one risk factor signify moderate risk of bleeding, if the single risk factor is severe (such as severe thrombocytopenia or recent major surgery) then the patient is at high risk of bleeding despite the presence of a single risk factor.

Risk of bleeding	Number of risk factors^[2]
Low Risk	0
Moderate Risk	1
High Risk	≥2

Do's

When indicated, administer fibrinolytic therapy for a short infusion time (for 2 hours) rather than over prolonged perfusion (for 24 hours).^[2]

When indicated, administer fibrinolytic therapy via a peripheral vein rather than pulmonary artery catheter. ^[2]

Begin anticoagulation therapy among high-risk patients suspected to have pulmonary embolism and those with high or intermediate pre-test probability of pulmonary embolism during the diagnostic workup while awaiting confirmatory tests.^[2]
If long term anticoagulation is extended for a longer period beyond 3 months, the same drug initially started should be continued.^[2]
Among patients started on heparin, if the risk of heparin induced thrombocytopenia is more than 1%, monitor platelet count every 2 to 3 days from the 4th until the 14th day of treatment or until the discontinuation of heparin.^[2]
Screen for thrombophilia if this is a first episode of VTE in a patient less than 50 years of age.^[2]

References

↑ Miniati M, Cenci C, Monti S, Poli D (2012). "Clinical presentation of acute pulmonary embolism: survey of 800 cases". PLoS One. 7 (2): e30891. doi:10.1371/journal.pone.0030891. PMC 3288010. PMID 22383978.
↑ ^2.00 ^2.01 ^2.02 ^2.03 ^2.04 ^2.05 ^2.06 ^2.07 ^2.08 ^2.09 ^2.10 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.
↑ ^3.00 ^3.01 ^3.02 ^3.03 ^3.04 ^3.05 ^3.06 ^3.07 ^3.08 ^3.09 ^3.10 ^3.11 ^3.12 ^3.13 ^3.14 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
↑ ^4.0 ^4.1 ^4.2 ^4.3 ^4.4 ^4.5 ^4.6 ^4.7 ^4.8 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
↑ ^5.0 ^5.1 ^5.2 Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
↑ Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
↑ Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). "Use of a clinical model for safe management of patients with suspected pulmonary embolism". Ann Intern Med. 129 (12): 997–1005. PMID 9867786.
↑ ^8.0 ^8.1 ^8.2 ^8.3 Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb Haemost. 83 (3): 416–20. PMID 10744147.
↑ ^9.0 ^9.1 ^9.2 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer". Ann Intern Med. 135 (2): 98–107. PMID 11453709.
↑ ^10.0 ^10.1 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
↑ van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.
↑ ^12.0 ^12.1 ^12.2 ^12.3 ^12.4 Kucher N, Goldhaber SZ (2005). "Management of massive pulmonary embolism". Circulation. 112 (2): e28–32. doi:10.1161/CIRCULATIONAHA.105.551374. PMID 16009801.
↑ Fengler BT, Brady WJ (2009). "Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm". Am J Emerg Med. 27 (1): 84–95. doi:10.1016/j.ajem.2007.10.021. PMID 19041539.
↑ ^14.0 ^14.1 ^14.2 ^14.3 ^14.4 ^14.5 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.
↑ Stein PD, Hull RD, Raskob GE (2000). "Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests". Am J Med. 109 (4): 301–6. PMID 10996581.
↑ ^16.0 ^16.1 ^16.2 ^16.3 ^16.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
↑ ^17.0 ^17.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.
↑ Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. doi:10.1148/radiology.189.1.8372182. PMID 8372182.
↑ Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658. Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4

[pmid22383978-1] Miniati M, Cenci C, Monti S, Poli D (2012). "Clinical presentation of acute pulmonary embolism: survey of 800 cases". PLoS One. 7 (2): e30891. doi:10.1371/journal.pone.0030891. PMC 3288010. PMID 22383978.

[pmid22315268-2] 2.00 ^2.01 ^2.02 ^2.03 ^2.04 ^2.05 ^2.06 ^2.07 ^2.08 ^2.09 ^2.10 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMC 3278049. PMID 22315268.

[pmid18757870-3] 3.00 ^3.01 ^3.02 ^3.03 ^3.04 ^3.05 ^3.06 ^3.07 ^3.08 ^3.09 ^3.10 ^3.11 ^3.12 ^3.13 ^3.14 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.

[pmid21422387-4] 4.0 ^4.1 ^4.2 ^4.3 ^4.4 ^4.5 ^4.6 ^4.7 ^4.8 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.

[pmid8914880-5] 5.0 ^5.1 ^5.2 Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)

[pmid7752753-6] Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

[pmid9867786-7] Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). "Use of a clinical model for safe management of patients with suspected pulmonary embolism". Ann Intern Med. 129 (12): 997–1005. PMID 9867786.

[pmid10744147-8] 8.0 ^8.1 ^8.2 ^8.3 Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb Haemost. 83 (3): 416–20. PMID 10744147.

[pmid11453709-9] 9.0 ^9.1 ^9.2 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer". Ann Intern Med. 135 (2): 98–107. PMID 11453709.

[pmid17185658-10] 10.0 ^10.1 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.

[pmid16403929-11] van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.

[pmid16009801-12] 12.0 ^12.1 ^12.2 ^12.3 ^12.4 Kucher N, Goldhaber SZ (2005). "Management of massive pulmonary embolism". Circulation. 112 (2): e28–32. doi:10.1161/CIRCULATIONAHA.105.551374. PMID 16009801.

[pmid19041539-13] Fengler BT, Brady WJ (2009). "Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm". Am J Emerg Med. 27 (1): 84–95. doi:10.1016/j.ajem.2007.10.021. PMID 19041539.

[pmid22315259-14] 14.0 ^14.1 ^14.2 ^14.3 ^14.4 ^14.5 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.

[pmid10996581-15] Stein PD, Hull RD, Raskob GE (2000). "Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests". Am J Med. 109 (4): 301–6. PMID 10996581.

[pmid24182642-16] 16.0 ^16.1 ^16.2 ^16.3 ^16.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.

[pmid12814980-17] 17.0 ^17.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

[pmid8372182-18] Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. doi:10.1148/radiology.189.1.8372182. PMID 8372182.

[pmid23991658-19] Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S; et al. (2013). "Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism". N Engl J Med. 369 (15): 1406–15. doi:10.1056/NEJMoa1306638. PMID 23991658. Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4

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@@ Line 3: / Line 3: @@
 '''For pulmonary embolism prevention resident survival guide click [[Venous thromboembolism prevention resident survival guide|here]].'''
-{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Rim Halaby|Rim Halaby]]; {{PB}}; {{chetan}}
+'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{Rim}}; {{PB}}; {{chetan}}
 {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
@@ Line 17: / Line 17: @@
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pulmonary embolism resident survival guide#Complete Diagnostic Approach|Diagnosis]]
 |-
-! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pulmonary embolism resident survival guide#Long Term Treatment|Treatment]]
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pulmonary embolism resident survival guide#Long Term Treatment|Long term treatment]]
 |-
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pulmonary embolism resident survival guide#Do's|Do's]]
-|-
-! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Pulmonary embolism resident survival guide#Don'ts|Don'ts]]
 |}
 == Overview==
-[[Pulmonary embolism]] (PE) is the acute obstruction of the [[pulmonary artery]] or one of its branches by a [[thrombus]], [[Air embolism|air]], [[Tumor embolism|tumor]], or [[Fat embolism|fat]].  Most often, PE is due to a [[venous thrombosis|venous thrombus]] which has been dislodged from its site of formation in the deep veins of the lower extremities, a process referred to as [[venous thromboembolism]].  PE is a potentially lethal condition.  The patient can present with a range of signs and symptoms; however the typical presentation is characterized by [[dyspnea]] (78-81% of the cases), [[pleuritic chest pain]] (39-56% of the cases) and/or [[syncope]] (22-26% of the cases).<ref name="pmid22383978">{{cite journal| author=Miniati M, Cenci C, Monti S, Poli D| title=Clinical presentation of acute pulmonary embolism: survey of 800 cases. | journal=PLoS One | year= 2012 | volume= 7 | issue= 2 | pages= e30891 | pmid=22383978 | doi=10.1371/journal.pone.0030891 | pmc=PMC3288010 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22383978  }} </ref>  The diagnostic approach of PE depends on whether the patient is a high-risk patient due to the presence of [[hypotension]] and/or [[shock]] or non-high risk patient, as well as on the pre-test probability of this disease.  While [[fibrinolytic therapy]] is the treatment of choice for patients with massive [[PE]], patients with non-massive PE are treated with [[anticoagulation therapy]].
+[[Pulmonary embolism]] (PE) is the acute obstruction of the [[pulmonary artery]] or one of its branches by a [[thrombus]], [[Air embolism|air]], [[Tumor embolism|tumor]], or [[Fat embolism|fat]].  Most often, PE is due to a [[venous thrombosis|venous thrombus]] which has been dislodged from its site of formation in the deep veins of the lower extremities, a process referred to as [[venous thromboembolism]].  PE is a potentially lethal condition.  The patient can present with a range of signs and symptoms; however, the typical presentation is characterized by [[dyspnea]] (78-81% of the cases), [[pleuritic chest pain]] (39-56% of the cases), and/or [[syncope]] (22-26% of the cases).<ref name="pmid22383978">{{cite journal| author=Miniati M, Cenci C, Monti S, Poli D| title=Clinical presentation of acute pulmonary embolism: survey of 800 cases. | journal=PLoS One | year= 2012 | volume= 7 | issue= 2 | pages= e30891 | pmid=22383978 | doi=10.1371/journal.pone.0030891 | pmc=PMC3288010 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22383978  }} </ref>  The diagnostic approach of PE depends on whether the patient is a high-risk patient due to the presence of [[hypotension]] and/or [[shock]] or a non-high risk patient, as well as on the pre-test probability of this disease.  While [[fibrinolytic therapy]] is the treatment of choice for patients with massive [[PE]], patients with non-massive PE are treated with [[anticoagulation therapy]].<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
 ==Causes==
@@ Line 33: / Line 31: @@
 ===Common Causes===
-* [[Blood clot]]
+* [[Blood clot]] (most common cause)
 * [[Air embolism|Air bubble]]
 * Fragment of a [[tumor]]
 * Fragment of [[fat]] (secondary to [[bone fracture]])
-* Talc in [[IV drug abusers]]
 * [[Amniotic fluid]]
@@ Line 43: / Line 40: @@
 ===Massive Pulmonary Embolism===
 Massive pulmonary embolism falls under the category "high risk patients" in the European guidelines. High risk PE patients have a risk of PE-related early mortality of > 15%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>  Massive PE is characterized by the presence of:
-*Sustained [[hypotension]] (systolic blood pressure <90 mm Hg), not due to [[arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], and either lasting for at least 15 minutes or necessitating the administration of inotropic support
+*Sustained [[hypotension]] (systolic blood pressure <90 mm Hg) not due to [[arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], that is either lasting for at least 15 minutes or necessitating the administration of [[inotropes]]
 OR<br>
 *[[PEA|Pulselessness]]
@@ Line 53: / Line 50: @@
 * [[Right ventricular dysfunction]] OR [[myocardial necrosis]]
 AND <br>
-* Absence of [[hypotension|systemic hypotension]] (systolic blood pressure >90 mm Hg)<ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref> <ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
+* Absence of [[hypotension|systemic hypotension]] (systolic blood pressure >90 mm Hg)<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
 ====Right Ventricular Dysfunction====
-[[Right ventricular dysfunction|Right ventricular (RV) dysfunction]] is characterized by the presence of AT LEAST ONE of the following:<ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref> <ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
+[[Right ventricular dysfunction|Right ventricular (RV) dysfunction]] is characterized by the presence of AT LEAST ONE of the following:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
 *[[Echocardiography]] findings:
 ** [[RV]] dilation (ratio of apical 4-chamber [[RV]] diameter to [[LV|left ventricle (LV)]] diameter > 0.9)
@@ Line 69: / Line 66: @@
 ====Myocardial Necrosis====
-[[Myocardial necrosis]]is defined as the presence of:<ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref> <ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
+[[Myocardial necrosis]]is defined as the presence of:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
 *Elevation of [[troponin I]] (>0.4 ng/mL)
 OR <br>
@@ Line 75: / Line 72: @@
 ===Low-Risk Pulmonary Embolism ===
-Low risk PE patients have a risk of PE-related early mortality of <1%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>  Low risk PE is characterized by the absence of [[hypotension]], [[shock]], [[RV dysfunction]] and [[myocardium|myocardial]] necrosis.<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
+Low risk PE patients have a risk of PE-related early mortality of <1%.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>  Low risk PE is characterized by the absence of [[hypotension]], [[shock]], [[RV dysfunction]], and [[myocardium|myocardial]] necrosis.<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
 ==FIRE: Focused Initial Rapid Evaluation==
@@ Line 92: / Line 89: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A02 | | | | | | | | | | | | | | | | | A03 |  A02= '''Suspected [[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">high-risk PE</span>]]'''| A03= '''Suspected [[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">non-high risk PE</span>]]'''}}
 {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
-{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A04 | | | | | | | | | | | | | | | | | |!| A04= ❑ ''Administer [[anticoagulation|<span style="color:white;">anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''}}
+{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A04 | | | | | | | | | | | | | | | | | |!| A04= ❑ ''Administer [[anticoagulation|<span style="color:white;">parenteral anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''}}
 {{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| }}
-{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | B01 | | | | | | | | | | | | | | | | | B02| B01= '''Is a [[CT|<span style="color:white;">CT</span>]] available immediately?'''| B02= '''What is the pretest probability of PE?''' <br> <div style="float: left; text-align: left; padding:1em;">Use one of the risk score:<br>❑ [[Pulmonary embolism resident survival guide#Wells Score|<span style="color:white;">Wells score</span>]] <br> ❑ [[Geneva score|<span style="color:white;">Geneva score</span>]] <br> ❑ [[PERC|<span style="color:white;">PERC</span>]] </div>}}
+{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | B01 | | | | | | | | | | | | | | | | | B02| B01= '''Is a [[CT|<span style="color:white;">CT</span>]] available immediately?'''| B02= '''[[Pulmonary embolism resident survival guide#Assessment of the Pretest Probability of PE|<span style="color:white;">What is the pretest probability of PE?</span>]]''' }}
 {{familytree | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | |,|-|v|-|^|-|-|.| | }}
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | C01 | | | | | | | | | | C02 | | | | | |!| |!| | | | |!| | C01= No| C02= Yes}}
@@ Line 102: / Line 99: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | E01 | | | | | | | | | | |!| | | | | E02 | | E03 | | E04 |  E01= '''Does the patient have [[RV|<span style="color:white;">RV</span>]] overload?'''| E02= '''[[Pulmonary embolism resident survival guide#Wells Score|<span style="color:white;">Low pretest probability</span>]]''' |E03= '''[[Pulmonary embolism resident survival guide#Wells Score|<span style="color:white;">Intermediate pretest probability</span>]]'''| E04= '''[[Pulmonary embolism resident survival guide#Wells Score|<span style="color:white;">High pretest probability</span>]]''' <br>OR<br> '''PE is likely'''}}
 {{familytree | | | |!| | | | | | | | | | | |!| | | | | | |!| |!| | | | |!| }}
-{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | |!| | | | | | | | | | | |!| | | | | | |!| | N01 | | N02 | N01= ❑ ''Administer [[anticoagulation|<span style="color:white;">anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''|N02= ❑ ''Administer [[anticoagulation|<span style="color:white;">anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''}}
+{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | |!| | | | | | | | | | | |!| | | | | | |!| | N01 | | N02 | N01= ❑ ''Administer [[anticoagulation|<span style="color:white;">parenteral anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''|N02= ❑ ''Administer [[anticoagulation|<span style="color:white;">anticoagulation</span>]]'' <br>''(in case there are no [[Pulmonary embolism resident survival guide#Contraindications to Anticoagulation|<span style="color:white;">contraindications</span>]])''<br>''during the diagnostic workup''}}
 {{familytree | |,|-|^|-|-|-|.| | | | | | | |!| | | | | | |!| |!| | | | |!| | }}
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | | | F02 | | | | | | F03 | | | | | | F04 | | | | |!| F01= No| F02= Yes| F03= ❑ '''Order [[CT|<span style="color:white;">CT</span>]]'''| F04= ❑ '''Order [[D-dimer|<span style="color:white;">D-dimer</span>]]'''}}
@@ Line 120: / Line 117: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | L01 | | | | L01= [[Pulmonary embolism resident survival guide#Step 2: Initial Treatment|<span style="color:white;">Click here for the initial treatment</span>]]}}
 {{familytree/end}}
+====Assessment of the Pretest Probability of PE====
+The assessment of the pretest  probability of PE can be achieved through scoring systems. The most commonly used score is the [[Wells score for PE|Wells score]].  Other scores, such as [[Geneva score]] and [[PERC]] can also be used.
 ==== Wells Score ====
@@ Line 125: / Line 125: @@
 ===== Calculation of Wells Score=====
-'''[[Wells score calculator|Wells Score Calculator for PE]]'''
+'''[[Wells score calculator|Pulmonary embolism Wells Score Calculator]]'''
 {| style="cellpadding=0; cellspacing= 0; width: 600px;"
@@ Line 149: / Line 149: @@
 ===== Interpretation of Wells Score=====
 ===== Wells Criteria =====
-* The following scoring system is used to assess the possible risk to a patient.<ref name="pmid10744147"/><ref name="pmid11453709"/><ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref> It also shows if there is a need for further testing with [[Pulmonary embolism D-dimer|D-dimer]] or [[Pulmonary embolism CT|CT]] scan:
+Shown below is the pretest probability of PE according to Wells criteria.<ref name="pmid10744147"/><ref name="pmid11453709"/><ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref>
+* Score >6.0: High probability (Rate of PE: ~66.7%)
-:* Score >6.0 - High probability (~59%).
+* Score 2.0 to 6.0: Moderate probability (Rate of PE: ~20.5%)
-:* Score 2.0 to 6.0 - Moderate probability (~29%).
+* Score <2.0: Low probability (Rate of PE: ~3.6%)
-:* Score <2.0 - Low probability (~15%).
 =====Modified Wells Criteria=====
-The following is the pretest probability of PE according to the modified Wells Criteria.<ref name="pmid16403929">{{cite journal| author=van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al.| title=Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. | journal=JAMA | year= 2006 | volume= 295 | issue= 2 | pages= 172-9 | pmid=16403929 | doi=10.1001/jama.295.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403929  }} </ref>
+Shown below is the pretest probability of PE according to the modified Wells Criteria.<ref name="pmid10744147"/><ref name="pmid11453709"/><ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref><ref name="pmid16403929">{{cite journal| author=van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al.| title=Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. | journal=JAMA | year= 2006 | volume= 295 | issue= 2 | pages= 172-9 | pmid=16403929 | doi=10.1001/jama.295.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403929  }} </ref>
-:* Score > 4 - PE likely. Consider diagnostic imaging.
+:* Score > 4: PE likely (Rate of PE: ~40.7%)
-:* Score 4 or less - PE unlikely. Consider [[Pulmonary embolism D-dimer|D-dimer]] to rule out PE.
+:* Score 4 or less: PE unlikely (Rate of PE: ~7.8%)
 ===Step 2: Initial Treatment===
@@ Line 166: / Line 165: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | | | | | A01 | | | | | | | | | | | | A01= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Assess the severity of pulmonary embolism</span>]]'''}}
 {{familytree | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.| | | | | }}
-{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | B01 | | | | | | B02 | | | | | | B03 | | | | B01= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Massive PE</span>]]''' <br> ''(also known as high-risk PE)'' <br> [[Cardiogenic shock|<span style="color:white;">Cardiogenic shock</span>]] <br> OR<br> Persistent [[hypotension|<span style="color:white;">hypotension</span>]] (≤90mmHg)<br> OR<br> Drop of the [[blood pressure|<span style="color:white;">blood pressure</span>]] by ≥ 40mmHg for > 15 min<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br> OR <br> [[Pulselessness|<span style="color:white;">Pulselessness</span>]] <br> OR<br> Profound [[bradycardia|<span style="color:white;">bradycardia</span>]] (<40 bpm) with findings of shock<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>| B02= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Submassive PE</span>]]''' <br> ''(also know as intermediate-risk PE)'' <br> [[RV dysfunction|<span style="color:white;">Right ventricular dysfunction</span>]] <br> AND/OR <br> Myocardial injury ([[Troponon|<span style="color:white;">Troponin</span>]] +)| B03= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Low-risk PE</span>]]''' <br> No [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]] <br> AND <br> No [[hypotension|<span style="color:white;">hypotension</span>]] <br> AND <br> No [[right ventricular dysfunction|<span style="color:white;">right ventricular dysfunction</span>]] <br> AND <br> No myocardial injury ([[Troponin|<span style="color:white;">Troponin</span>]] -)}}
+{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | B01 | | | | | | B02 | | | | | | B03 | | | | B01= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Massive PE</span>]]''' <br> ''(also known as high-risk PE)'' <br> [[Cardiogenic shock|<span style="color:white;">Cardiogenic shock</span>]] <br> OR<br> Persistent [[hypotension|<span style="color:white;">hypotension</span>]] (≤90mmHg)<br> OR<br> Drop of the [[blood pressure|<span style="color:white;">blood pressure</span>]] by ≥ 40mmHg for > 15 min<ref name="pmid16009801">{{cite journal| author=Kucher N, Goldhaber SZ| title=Management of massive pulmonary embolism. | journal=Circulation | year= 2005 | volume= 112 | issue= 2 | pages= e28-32 | pmid=16009801 | doi=10.1161/CIRCULATIONAHA.105.551374 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16009801  }} </ref><br> OR <br> [[Pulselessness|<span style="color:white;">Pulselessness</span>]] <br> OR<br> Profound [[bradycardia|<span style="color:white;">bradycardia</span>]] (<40 bpm) with findings of shock<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>| B02= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Submassive PE</span>]]''' <br> ''(also know as intermediate-risk PE)'' <br> [[Pulmonary embolism resident survival guide#Right Ventricular Dysfunction|<span style="color:white;">Right ventricular dysfunction</span>]] <br> AND/OR <br> [[Pulmonary embolism resident survival guide#Myocardial Necrosis|<span style="color:white;">Myocardial injury</span>]] ([[Troponin|<span style="color:white;">Troponin</span>]] +)| B03= '''[[Pulmonary embolism resident survival guide#Classification|<span style="color:white;">Low-risk PE</span>]]''' <br> No [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]] <br> AND <br> No [[hypotension|<span style="color:white;">hypotension</span>]] <br> AND <br> No [[Pulmonary embolism resident survival guide#Right Ventricular Dysfunction|<span style="color:white;">right ventricular dysfunction</span>]] <br> AND <br> No [[Pulmonary embolism resident survival guide#Myocardial Necrosis|<span style="color:white;">myocardial injury</span>]] ([[Troponin|<span style="color:white;">Troponin</span>]] -)}}
 {{familytree | | | |!| | | | | | | |!| | | | | | | |!| | | | | }}
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | B04 | | | | | | |!| | | | | | | |!| | | | | B04= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Provide hemodynamic and respiratory support''' <br>
@@ Line 182: / Line 181: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E01= ❑ Discontinue [[heparin|<span style="color:white;">unfractionated heparin</span>]] <br> AND <br> ❑ Begin [[fibrinolytic therapy|<span style="color:white;">fibrinolytic therapy</span>]]| E02= ❑ Surgical [[pulmonary embolectomy|<span style="color:white;">pulmonary embolectomy</span>]] <br> OR <br> ❑ Percutaneous catheter [[pulmonary embolectomy|<span style="color:white;">embolectomy</span>]]| E03= ❑ [[Anticoagulationt therapy|<span style="color:white;">Anticoagulation therapy</span>]] <br> AND <br> ❑ Hospital admission|E04= ❑ [[IVC filter|<span style="color:white;">IVC filter</span>]] <br>AND <br>❑ Hospital admission| E05= ❑ [[Anticoagulationt therapy|<span style="color:white;">Anticoagulation therapy</span>]]<br> AND <br> ❑ Early discharge/home treatment| E06= ❑ [[IVC filter|<span style="color:white;">IVC filter</span>]] <br> AND <br> ❑ Early discharge/home treatment}}
 {{familytree | |!| | | | | | | | |!| |!| | | | }}
-{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | | | | | | | F02 | | | | F01= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]]?'''<br> OR <br> '''Develop [[hypotension|<span style="color:white;">hypotension</span>]]?'''| F02= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]]?'''<br> OR <br> '''Develop [[hypotension|<span style="color:white;">hypotension</span>]] (<90 mmHg)?''' <br> OR <br> '''Develop [[respiratory distress|<span style="color:white;">respiratory distress</span>]] (SaO2<95% with [[Borg score|<span style="color:white;">Borg score</span>]]>8 or altered mental status)''' <br> OR <br> '''Have moderate to severe [[RV dysfunction|<span style="color:white;">RV dysfunction</span>]] (RV hypokinesis or estimated RVSP>40 mmHg)''' <br> OR <br> '''Elevated biomarkers ([[troponin|<span style="color:white;">troponin</span>]]> upper limit of normal, [[BNP|<span style="color:white;">BNP</span>]]>100 pg/mL, or [[pro-BNP|<span style="color:white;">pro-BNP</span>]]>900 pg/mL)'''<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>}}
+{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F01 | | | | | | | | F02 | | | | F01= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]]'''<br> OR <br> '''Develop [[hypotension|<span style="color:white;">hypotension</span>]]?'''| F02= '''Does the patient fail to improve''' <br> OR <br> '''Develop [[cardiogenic shock|<span style="color:white;">cardiogenic shock</span>]]'''<br> OR <br> '''Develop [[hypotension|<span style="color:white;">hypotension</span>]] (<90 mmHg)''' <br> OR <br> '''Develop [[respiratory distress|<span style="color:white;">respiratory distress</span>]] (SaO2<95% with [[Borg score|<span style="color:white;">Borg score</span>]]>8 or altered mental status)''' <br> OR <br> '''Have moderate to severe [[Pulmonary embolism resident survival guide#Right Ventricular Dysfunction|<span style="color:white;">RV dysfunction</span>]] (RV hypokinesis or estimated RVSP>40 mmHg)''' <br> OR <br> '''Have elevated biomarkers ([[troponin|<span style="color:white;">troponin</span>]]> upper limit of normal, [[BNP|<span style="color:white;">BNP</span>]]>100 pg/mL, or [[pro-BNP|<span style="color:white;">pro-BNP</span>]]>900 pg/mL)?'''<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>}}
 {{familytree |,|^|-|-|-|.| | | |,|-|^|-|.| | | | }}
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | F03 | | F04 | | F05 | | F06 | | | F03= YES| F04= NO| F05= YES| F06= NO}}
@@ Line 198: / Line 197: @@
 {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | L01 | | L02 | L01= ❑ [[Pulmonary embolectomy|<span style="color:white;">Surgical pulmonary embolectomy</span>]] <br> OR <br> ❑ [[Pulmonary embolectomy|<span style="color:white;">Percutaneous catheter embolectomy</span>]]| L02= ❑ Continue with the same treatment}}
 {{familytree/end}}
+===Dosage of Fibrinolytic Therapy===
+Shown below is the dosage schedule for the thrombolytic agents:<ref name="pmid21422387">{{cite journal|author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.|title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387|doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387  }} </ref>
+*[[Streptokinase]] (FDA-approved)
+**'''Loading dose:''' 250 000 IU over 30 min
+**'''Maintenance dose:''' 100 000 IU/h over 12–24 hr
+**'''Accelerated regimen:''' 1.5 million IU over 2 hr
+*[[Urokinase]] (FDA-approved)
+**'''Loading dose:''' 4400 IU/kg over 10 min
+**'''Maintenance dose:''' 4400 IU/kg/h over 12–24 hr
+**'''Accelerated regimen:''' 3 million IU over 2 hr
+*[[Recombinant tissue plasminogen activator|Recombinant tissue plasminogen activator (rtPA)]]<ref name="pmid19041539">{{cite journal| author=Fengler BT, Brady WJ| title=Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm. | journal=Am J Emerg Med | year= 2009 | volume= 27 | issue= 1 | pages= 84-95 |pmid=19041539 | doi=10.1016/j.ajem.2007.10.021 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19041539  }} </ref>
+** [[Alteplase]] (FDA-approved): 10-mg IV bolus followed by 90 mg IV infusion over 2 hours
+** [[Reteplase]]: 10-U IV bolus followed in 30 mins by another 10-U IV bolus
+** [[Tenecteplase]]: 0.5-mg/kg IV bolus (max 50mg)
+===Contraindications to Fibrinolytic Therapy===
+Shown below is a table summarizing the absolute and relative contraindications to [[fibrinolytic therapy]] among [[pulmonary embolism]] patients.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Absolute contraindications'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Relative contraindications'''
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ Previous [[hemorrhagic stroke]] or [[stroke]] of unknown origin <br>
+❑ [[Ischemic stroke]] within the last 6 months<br>
+❑ [[Central nervous system]] tumor or damage <br>
+❑ Major [[trauma]], head injury, or [[surgery]] within the last 3 weeks <br>
+❑ [[Gastrointestinal bleed]] within the last month <br>
+❑ Known [[bleeding]] <br>
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ [[Transient ischemic attack]] within the last 6 months <br>
+❑ [[Anticoagulation|Oral anticoagulant therapy]] intake <br>
+❑ Advanced [[liver disease]] <br>
+❑ [[Infective endocarditis]] <br>
+❑ [[Peptic ulcer disease]] that is currently active <br>
+❑ [[Pregnancy]] or within 1 week post partum <br>
+❑ Punctures that are non-compressible <br>
+❑ [[Resuscitation|Traumatic resuscitation]] <br>
+❑ [[Systolic blood pressure]] >180 mmHg refractory to treatment
+|}
 ===Choice of Initial Anticoagulation Therapy===
@@ Line 206: / Line 244: @@
 {{familytree | | | | B01 | | | | | | B01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Is the patient high risk or non-high risk?''' </div>}}
 {{familytree | |,|-|-|^|-|-|.| | | | }}
-{{familytree | C01 | | | | C02 | | | C01= '''High risk'''| C02= '''Non-high risk'''}}
+{{familytree | C01 | | | | C02 | | | C01= '''[[Pulmonary embolism resident survival guide#Massive Pulmonary Embolism|High risk]]'''| C02= '''[[Pulmonary embolism resident survival guide#Classification|Non-high risk]]'''}}
 {{familytree | |!| | | | | |!| | | | }}
 {{familytree | D01 | | | | D02 | | | D01=
@@ Line 266: / Line 304: @@
 *[[Surgery]] within the prior 14 days
 *[[Stroke|Thrombotic stroke]] within the prior 14 days<ref name="pmid10996581">{{cite journal| author=Stein PD, Hull RD, Raskob GE| title=Withholding treatment in patients with acute pulmonary embolism who have a high risk of bleeding and negative serial noninvasive leg tests. | journal=Am J Med | year= 2000 | volume= 109 | issue= 4 | pages= 301-6 | pmid=10996581 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10996581  }} </ref>
-===Contraindications to Fibrinolytic Therapy===
-Shown below is a table summarizing the absolute and relative contraindications to [[fibrinolytic therapy]] among [[pulmonary embolism]] patients.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
-{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-|-
-| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Absolute contraindications'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Relative contraindications'''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ Previous [[hemorrhagic stroke]] or [[stroke]] of unknown origin <br>
-❑ [[Ischemic stroke]] within the last 6 months<br>
-❑ [[Central nervous system]] tumor or damage <br>
-❑ Major [[trauma]], head injury, or [[surgery]] within the last 3 weeks <br>
-❑ [[Gastrointestinal bleed]] within the last month <br>
-❑ Known [[bleeding]] <br>
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |❑ [[Transient ischemic attack]] within the last 6 months <br>
-❑ [[Anticoagulation|Oral anticoagulant therapy]] intake <br>
-❑ Advanced [[liver disease]] <br>
-❑ [[Infective endocarditis]] <br>
-❑ [[Peptic ulcer disease]] that is currently active <br>
-❑ [[Pregnancy]] or within 1 week post partum <br>
-❑ [[Punctures]] that are non-compressible <br>
-❑ [[Rescusitation|Traumatic resuscitation]] <br>
-❑ [[Systolic blood pressure]] >180 mmHg refractory to treatment
-|}
 ==Complete Diagnostic Approach==
@@ Line 310: / Line 324: @@
 ❑ Findings suggestive of [[DVT]] (15%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
 :❑ Calf or thigh pain and swelling
-:❑ [[Edema]], [[erythema]], [[tenderness]], or a palpable cord in the calf or thigh </div>}}
+:❑ [[Edema]], [[erythema]], [[tenderness]], or a palpable cord in the calf or thigh
+❑ Symptoms suggestive of [[shock]] (in case of [[Pulmonary embolism resident survival guide#Massive Pulmonary Embolism|massive PE]])
+:❑ [[Altered mental status]]
+:❑ [[Cold extremities]]
+:❑ [[Cyanosis]]
+:❑ [[Oliguria]]</div>}}
 {{familytree  | |!| | |}}
-{{familytree  | B01 | |  B01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Identify predisposing factors:'''<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
+{{familytree  | B01 | |  B01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Elicit a detailed history:'''<br>
-'''''Strong risk factors'''''<br>
+❑ '''Risk factors'''<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref>
-❑ [[Bone fracture]] ([[hip]] or [[leg]]) <br>
+:❑ [[Chemotherapy]]<br>
-❑ [[Hip replacement surgery]]<br>
+:❑ [[Chronic heart failure]]<br>
-❑ Knee replacement surgery<br>
+:❑ [[Respiratory failure]]<br>
-❑ [[General surgery|Major general surgery]]<br>
+:❑ [[Hormone replacement therapy]]<br>
-❑ [[Trauma|Significant trauma]]<br>
+:❑ [[Cancer]]<br>
-❑ [[Spinal cord injury]]<br>
+:❑ [[Oral contraceptive pills]] <br>
-'''''Moderate risk factors'''''<br>
+:❑ [[Stroke]] <br>
-❑ Athroscopic knee surgery<br>
+:❑ [[Pregnancy]] <br>
-❑ [[Central venous line]]s<br>
+:❑ [[Postpartum]] <br>
-❑ [[Chemotherapy]]<br>
+:❑ Prior history of [[VTE]] <br>
-❑ [[Chronic heart failure]]<br>
+:❑ [[Thrombophilia]] <br>
-❑ [[Respiratory failure]]<br>
+:❑ Advanced [[age]] <br>
-❑ [[Hormone replacement therapy]]<br>
+:❑ [[Laparoscopic surgery]] <br>
-❑ [[Cancer]]<br>
+:❑ Prepartum <br>
-❑ [[Oral contraceptive pills]] <br>
+:❑ [[Obesity]] <br>
-❑ [[Stroke]] <br>
+:❑ [[Varicose veins]]
-❑ [[Pregnancy]] <br>
+❑ '''Triggers'''<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref>
-❑ [[Postpartum]] <br>
+:❑ [[Bone fracture]] ([[hip]] or [[leg]]) <br>
-❑ Prior history of [[VTE]] <br>
+:❑ [[Hip replacement surgery]]<br>
-❑ [[Thrombophilia]] <br>
+:❑ Knee replacement surgery<br>
-'''''Weak risk factors'''''<br>
+:❑ [[General surgery|Major general surgery]]<br>
-❑ Bed rest for more than 3 days <br>
+:❑ [[Trauma|Significant trauma]]<br>
-❑ Prolonged car or air travel <br>
+:❑ [[Spinal cord injury]]<br>
-❑ Advanced [[age]] <br>
+:❑ Athroscopic knee surgery<br>
-❑ [[Laparoscopic surgery]] <br>
+:❑ [[Central venous line]]s<br>
-❑ Prepartum <br>
+:❑ [[Chemotherapy]]<br>
-❑ [[Obesity]] <br>
+:❑ Bed rest for more than 3 days <br>
-❑ [[Varicose veins]]
+:❑ Prolonged car or air travel <br>
-----
+:❑ [[Laparoscopic surgery]] <br>
+:❑ Prepartum <br>
-'''Obtain a detailed history:''' <br>
+❑ '''Previous episode of [[VTE]]'''
-❑ [[Autoimmune diseases]]<br>
+:❑ Age
-❑ [[Hyperviscosity syndrome]]<br>
+:❑ Location
-:❑ Deficiencies of [[antithrombin]], [[protein C]], and [[protein S]]<br>
+❑ '''Past medical history of diseases associated with hyperviscosity'''
-:❑ [[Polycythemia vera]]<br>
+:❑ [[Atherosclerosis]]
-:❑ [[Leukemias]]<br>
+:❑ [[Collagen vascular disease]]
-:❑ [[Hyperhomocysteinemia]]<br>
+:❑ [[Heart failure]]
-:❑ [[Myeloproliferative neoplasms]]<br>
+:❑ [[Myeloproliferative disease]]
-:❑ [[Paroxysomal nocturnal hemoglobinuria]]<br>
+:❑ [[Nephrotic syndrome]]
-:❑ [[Waldenstrom macroglobulinemia]]<br>
+:❑ [[Autoimmune diseases]]
-:❑ [[Multiple myeloma]]<br>
+:❑[[Polycythemia vera]]
-❑ Previous history of recurent [[miscarriage]]s
+:❑ [[Hyperhomocysteinemia]]
-❑ Family history (suggestive of [[inherited thrombophilia]]) <br>
+:❑ [[Paroxysmal nocturnal hemoglobinuria]]
-:❑ [[Deep vein thrombosis]] <br>
+:❑ [[Waldenstrom macroglobulinemia]]
-:❑ [[Pulmonary embolism]] <br>
+:❑ [[Multiple myeloma]]
-:❑ [[Recurrent miscarriage]]
+❑ '''History of [[thrombophilia]]'''
-❑ Social history (increased risk in females) <br>
+:❑ [[Factor V Leiden mutation]]
-:❑ [[Heavy cigarette smoking]] (>25 cigarettes per day)<br>
+:❑ [[Prothrombin gene mutation G20210A]]
-:❑ Intravenous drug use (if injected directly in femoral vein)<br>
+:❑ [[Protein C]] or [[Protein S]] deficiency
-:❑ [[Alcohol]] <br>
+:❑ [[Antithrombin]] (AT) deficiency
-❑ Medications <br>
+:❑ [[Antiphospholipid syndrome]] (APS)
-:❑ [[Hormone replacement therapy]] <br>
+❑ '''Abortion'''
-:❑ [[Tamoxifen]] <br>
+:❑ [[Abortion]] at second or third trimester of [[pregnancy]] (suggestive of an inherited [[thrombophilia]] or [[APS]])
-:❑ [[Bevacizumab]] <br>
+❑ '''Drugs that may increase the risk of VTE'''
-:❑ [[Glucocorticoids]] <br>
+:❑ [[Hydralazine]]
+:❑ [[Phenothiazine]]
+:❑ [[Procainamide]]
+:❑ [[Tamoxifen]]
+:❑ [[Bevacizumab]]
+:❑ [[Glucocorticoids]]
+❑ '''Family history (suggestive of [[inherited thrombophilia]])'''
+:❑ [[Deep vein thrombosis]]
+:❑ [[Pulmonary embolism]]
+:❑ Recurrent [[miscarriage]]
+❑ '''Social history'''
+:❑ Heavy [[cigarette smoking]] (>25 cigarettes per day)
+:❑ [[Intravenous drug use]] (if injected directly in [[femoral vein]])
+:❑ [[Alcohol]]
 </div>}}
 {{familytree  | |!| | | }}
@@ Line 376: / Line 408: @@
 ❑ [[Blood pressure]] <br>
 :❑ [[Blood pressure]] lower than baseline, suggestive of [[cardiogenic shock]] (associated with [[tachycardia]] and end organ hypoperfusion)
-❑ [[Tachycardia]] (26%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br><br>
+❑ [[Tachycardia]] (26%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
-❑ [[Tachypnea]] (70%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br><br>
+❑ [[Tachypnea]] (70%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
 ❑ [[Low grade fever]] <br>
@@ Line 408: / Line 440: @@
 :❑ [[Sinus tachycardia]]
 :❑ Stress on the [[right ventricle]]
-:❑ Axis deviation to the right
+:❑ [[Right axis deviation]]
 :❑ [[Right bundle branch block]]
 :❑ S1Q3T3
@@ Line 414: / Line 446: @@
 ::❑ [[Q wave]] in [[lead III]]
 :❑ [[Inverted T wave]] in [[lead III]]
-❑ [[Chest X Ray]]<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182  }} </ref>
+❑ [[Chest X ray]]<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182  }} </ref>
 :❑ [[Atelectasis]] (most common)
 :❑ [[Fleishner sign]]: enlarged pulmonary artery
@@ Line 426: / Line 458: @@
 {{Family tree/end}}
-==Long Term Management==
+==Long Term Treatment==
-The long term management of [[PE]] depends on whether the episode is the first episode or not, whether it is provoked or unprovoked and the risk of bleeding of the patient.  Among non cancer patients, the first line therapy for long term management of [[PE]] is [[vitamin K antagonist]]s (VKA); whereas the first line treatment among cancer patients is [[low molecular weight heparin]].  '''If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the [[INR]] is ≥2 for at least 24 hours'''.  Among patients on extended [[anticoagulation therapy]], the risk vs benefits of the [[anticoagulation therapy]] should be assessed regularly (for example annually).<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
+The long term treatment of [[PE]] depends on whether the episode is the first one or not, whether it is provoked or unprovoked, and on the risk of bleeding of the patient.  Among non cancer patients, the first line therapy for long term management of [[PE]] is [[vitamin K antagonist]]s (VKA); whereas the first line treatment among cancer patients is [[low molecular weight heparin]].  '''If long term treatment with VKA is decided, VKA should be started at the same day with heparin allowing for at least 5 days of overlap until the [[INR]] is ≥2 for at least 24 hours'''.  Among patients on extended [[anticoagulation therapy]], the risk vs benefits of the [[anticoagulation therapy]] should be assessed regularly (for example annually).<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
 {{Family tree/start}}
-{{familytree | | | | | | | | | | A01 | | | | | | | | A01= '''Is this the first or second episode of PE?'''}}
+{{familytree | | | | | | | | | | A01 | | | | | | | | A01= '''Is this the first episode of PE?'''}}
 {{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | }}
-{{familytree | | | | | B01 | | | | | | | | B02 | | | B01= '''First episode'''| B02= '''Second episode'''}}
+{{familytree | | | | | B01 | | | | | | | | B02 | | | B01= '''YES'''| B02= '''NO'''}}
 {{familytree | | | | | |!| | | | | | | | | |!| | | | }}
 {{familytree | | | | | C01 | | | | | | | | C02 | | | C01= '''Is PE provoked?'''| C02= '''[[Pulmonary embolism resident survival guide#Assessment of Risk of Bleeding|What is the risk of bleeding?]]'''}}
@@ Line 446: / Line 478: @@
 {{familytree | | | | | | | H01 | | H02 | | | | | | | H01= '''Extended therapy'''| H02= '''Do not extend the therapy beyond the initial 3 months'''}}
 {{familytree/end}}
+''Note that [[edoxaban]]<ref name="pmid23991658">{{cite journal| author=Hokusai-VTE Investigators. Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S et al.| title=Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 15 | pages= 1406-15 | pmid=23991658 | doi=10.1056/NEJMoa1306638 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23991658  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24445714 Review in: Ann Intern Med. 2014 Jan 21;160(2):JC4]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24638182 Review in: Ann Intern Med. 2014 Mar 18;160(6):JC4] </ref> has been evaluated for the treatment of [[VTE]] and is currently seeking approval for this indication.''
 ===Vitamin K Antagonist===
-* Begin with 10 mg warfarin for 2 days followed by dosing based on the INR
+* Begin with 5 mg [[warfarin]] for 2 days followed by dosing based on the [[INR]].
-* Start at the 1st or 2nd day of the initial parenteral therapy
+* Start at the 1st or 2nd day of the initial parenteral therapy.
-* Target INR is 2-3
+* Target [[INR]] is 2-3.
-* Monitor INR:
+* Monitor [[INR]] monthly.
-** If stable, repeat INR every 12 weeks
+** If the INR is stable but there is one value 0.5 below or above the target range, continue the same dose and repeat [[INR]] within 1-2 weeks.
-** If stable but one value 0.5 below or above the target range, continue the same dose and repeat INR within 1-2 weeks
+* Avoid [[NSAID]]s, [[COX2]] selective NSAIDs and some antibiotics<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>
-* Avoid NSAIDs, COX2 selective NSAIDs and some antibiotics<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>
 ===Assessment of Risk of Bleeding===
@@ Line 491: / Line 525: @@
 * When indicated, administer [[fibrinolytic therapy]] for a short infusion time (for 2 hours) rather than over prolonged perfusion (for 24 hours).<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-* When indicated, administer [[fibrinolytic therapy]] via a peripheral vein rather than pulmonary artery catheter.
+* When indicated, administer [[fibrinolytic therapy]] via a peripheral vein rather than pulmonary artery catheter. <ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
-* Begin [[anticoagulation therapy]] among high-risk patients suspected to have [[pulmonary embolism]] and those with high or intermediate pre-test probability of [[pulmonary embolism]] during the diagnostic workup while awaiting confirmatory tests.
-* If long term anticoagulation is extended for a longer period beyond 3 months, the same drug initially started should be continued.
-* Among patients started on [[heparin]], if the risk of heparin induced thrombocytopenia is more than 1%, monitor platelet count every 2 to 3 days from the 4th until the 14th day of treatment or until the discontinuation of heparin.
-* Screen for thrombophilia if this is a first episode of [[VTE]] in a patient less than 50 years of age.
-==Don'ts==
+* Begin [[anticoagulation therapy]] among high-risk patients suspected to have [[pulmonary embolism]] and those with high or intermediate pre-test probability of [[pulmonary embolism]] during the diagnostic workup while awaiting confirmatory tests.<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
+* If long term anticoagulation is extended for a longer period beyond 3 months, the same drug initially started should be continued.<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
+* Among patients started on [[heparin]], if the risk of [[heparin induced thrombocytopenia]] is more than 1%, monitor [[platelet count]] every 2 to 3 days from the 4th until the 14th day of treatment or until the discontinuation of [[heparin]].<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
+* Screen for [[thrombophilia]] if this is a first episode of [[VTE]] in a patient less than 50 years of age.<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
 ==References==

Pulmonary embolism resident survival guide: Difference between revisions

Latest revision as of 19:38, 10 July 2014

Overview

Causes

Life Threatening Causes

Common Causes

Classification

Massive Pulmonary Embolism

Submassive Pulmonary Embolism

Right Ventricular Dysfunction

Myocardial Necrosis

Low-Risk Pulmonary Embolism

FIRE: Focused Initial Rapid Evaluation

Step 1: Confirm PE

Assessment of the Pretest Probability of PE

Wells Score

Calculation of Wells Score

Interpretation of Wells Score

Wells Criteria

Modified Wells Criteria

Step 2: Initial Treatment

Dosage of Fibrinolytic Therapy

Contraindications to Fibrinolytic Therapy

Choice of Initial Anticoagulation Therapy

Adjustment of Heparin Dosage According to aPTT

Contraindications to Anticoagulation

Complete Diagnostic Approach

Long Term Treatment

Vitamin K Antagonist

Assessment of Risk of Bleeding

Do's

References

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