Pulmonary Embolism

Management of Pulmonary Embolism

Written by – Dr Andrew Lam

Well’s Criteria for PE

Criteria	Score
Clinical Signs and Symptoms of DVT	3
PE is No. 1 Diagnosis or Equally Likely	3
Heart Rate >100 BPM	1.5
Immobilisation for 3+ Days or Surgery in Last 4 Weeks	1.5
Previous PE or DVT	1.5
Haemoptysis	1
Malignancy with Treatment Within 6 months or Palliative	1

Pulmonary Embolism Rule Out Criteria (PERC)

Criteria	Score
Age > 50	1
Heart Rate >100 BPM	1
SpO2 on Room Air <95%	1
Unilateral Leg Swelling	1
Haemoptysis	1
Recent Surgery or Trauma	1
Previous PE or DVT	1
Hormone Use	1

Low Probability of PE (Well’s Score <2) 

If PERC score is 0, then pulmonary embolism can be clinically ruled out
If PERC score is > 1, then D-Dimer needs to be measured

Intermediate Probability of PE (Well’s Score 2-6) 

Will require a D-Dimer

High Probability of PE (Well’s Score > 6) 

Go straight to CT Pulmonary Angiogram or V/Q Scan

D-Dimer

If D-Dimer <500ng/ml, then PE can be excluded, no further testing required
If D-Dimer >500ng/ml, then diagnostic test must be completed (CT Pulmonary Angiogram or V/Q Scan) 

Classifications of PE’s

Massive PE – PE resulting in haemodynamic instability 

Systolic BP <90 mmHg
OR
Drop in systolic BP > 40mmHg from baseline for >15 minutes
OR
Hypotension requiring vasopressor or inotropic support

Submassive PE – PE not fulfilling criteria of massive PE, but with: 

Right Ventricular Dysfunction
– ECG changes (RBBB, right ventricular strain pattern, right axis deviation)
– Echocardiographic changes
OR
Myocardial Necrosis
– Troponin Rise

Non-Massive PE – PE not fulfilling criteria for massive or submassive PE’s

References: 

Nickson, D. (2020). Pulmonary Embolism • LITFL • CCC Respiratory. Retrieved 22 September 2020, from https://litfl.com/pulmonary-embolism/

PERC Rule for Pulmonary Embolism – MDCalc. (2020). Retrieved 22 September 2020, from https://www.mdcalc.com/perc-rule-pulmonary-embolism

Thompson, B.T.., & Kabrhel, C. (2020). Overview of Acute Pulmonary Embolism in Adults. UpToDate. Retrieved September 22, 2020, from https://www.uptodate.com.acs.hcn.com.au/contents/overview-of-acute-pulmonary-embolism-in-adults

Wells’ Criteria for Pulmonary Embolism – MDCalc. (2020). Retrieved 22 September 2020, from https://www.mdcalc.com/wells-criteria-pulmonary-embolism