Pulmonary Embolism (PE) - CCS Case Guide
Key Takeaway: Pulmonary embolism is a potentially fatal condition caused by thrombus migration to the pulmonary vasculature. Risk stratification using Wells criteria and timely imaging are essential.
Pulmonary embolism is a potentially fatal condition caused by thrombus migration to the pulmonary vasculature. Risk stratification using Wells criteria and timely imaging are essential. Management ranges from anticoagulation to systemic thrombolysis in massive PE.
Recognizing the PE Presentation
- History: Acute dyspnea, pleuritic chest pain, cough, hemoptysis; risk factors include recent surgery, immobilization, malignancy, OCP use, or prior VTE
- Physical Exam: Tachypnea, tachycardia, hypoxia, unilateral leg swelling (DVT), possible JVD and right heart strain signs in massive PE
- Vital Signs: Tachycardia, tachypnea, hypoxia, possible hypotension in massive PE
Immediate Actions (First 5 Minutes)
These orders should be placed immediately — timing is scored:
Critical First Orders
- ✓ Supplemental oxygen
- ✓ IV access and continuous telemetry
- ✓ ECG
- ✓ Assess hemodynamic stability
- ✓ Empiric anticoagulation with heparin if high clinical suspicion
Complete Workup
After initial stabilization, complete the diagnostic workup:
- CT pulmonary angiography (gold standard)
- D-dimer (only if low-to-moderate pretest probability)
- ECG (sinus tachycardia, S1Q3T3, right heart strain)
- Troponin and BNP (risk stratification)
- CBC, BMP, coagulation studies
- Lower extremity duplex ultrasound if DVT suspected
- ABG (hypoxemia, respiratory alkalosis)
- Echocardiogram (RV dilation in submassive/massive PE)
- V/Q scan if CT angiography contraindicated
Treatment
Anticoagulation
- Unfractionated heparin IV drip (bolus 80 units/kg, then 18 units/kg/hr)
- OR enoxaparin 1 mg/kg subQ BID
- Transition to oral anticoagulant (rivaroxaban, apixaban, or warfarin)
- Duration: minimum 3 months; longer if unprovoked or recurrent
Massive PE (hemodynamically unstable)
- Systemic thrombolysis with alteplase 100 mg IV over 2 hours
- IV fluid bolus for preload support (use cautiously)
- Vasopressors (norepinephrine) if persistent hypotension
- Consider catheter-directed therapy or surgical embolectomy
Submassive PE (RV strain, stable)
- Anticoagulation with close monitoring
- Consider catheter-directed therapy in select cases
- Monitor for hemodynamic deterioration
IVC Filter
- Only if absolute contraindication to anticoagulation
- Or recurrent PE despite therapeutic anticoagulation
Common Pitfalls
Scoring Tip: These are the most commonly missed actions for PE cases.
- Ordering D-dimer in high-probability patients (go straight to CTA)
- Delaying anticoagulation while waiting for imaging
- Not assessing RV function to differentiate submassive from non-massive PE
- Failing to consider thrombolysis in massive PE with hemodynamic instability
- Forgetting to evaluate for underlying DVT
Disposition
- ICU admission for massive or submassive PE
- Telemetry floor for non-massive PE requiring IV heparin
- Consider outpatient management for low-risk PE (PESI score)
- Discharge on oral anticoagulation with hematology or PCP follow-up
Key Orders Checklist
- ☐ CT pulmonary angiography
- ☐ Heparin drip
- ☐ Troponin and BNP
- ☐ Echocardiogram
- ☐ Lower extremity duplex ultrasound
- ☐ Continuous telemetry and pulse oximetry
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