Pulmonary embolism
Pulmonary embolism is thrombus, usually from a lower-extremity deep vein thrombosis, obstructing the pulmonary arterial circulation and causing V/Q mismatch, right ventricular strain, and hypoxemia. Diagnosis follows Wells criteria (with PERC in low-risk patients) to sequence D-dimer, CT pulmonary angiography, and V/Q scanning, and management is risk-stratified anticoagulation escalating to thrombolysis or embolectomy for hemodynamic instability.
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What this article covers
- Overview
Thrombus obstructing the pulmonary arterial circulation: pulmonary embolism (PE) occurs when thrombus, almost always from a lower-extremity deep vein thrombosis (DVT), embolizes to the pulmonary…
- Epidemiology
Incidence of a first VTE episode is approximately 1 to 2 per 1000 person-years.
- Risk factors
Previous VTE: the strongest predictor of a new event, regardless of an additional thrombophilic risk factor.
- Pathophysiology
Mechanical obstruction raises pulmonary vascular resistance: thrombus occludes arterial branches, and hypoxic vasoconstriction of adjacent vessels from inflammatory mediators adds further resistance.
- Clinical features
Acute pleuritic chest pain and dyspnea with tachypnea and tachycardia: the classic presentation, often with ipsilateral leg swelling, tenderness, or erythema of a concurrent DVT.
- Differential diagnosis
Acute coronary syndrome: dynamic ST-segment change and a rising troponin curve with a wall-motion abnormality on echocardiography, versus sinus tachycardia and normal wall motion in PE.
- Diagnosis
PE is confirmed by an intraluminal filling defect on CT pulmonary angiography (CTA), or a high-probability V/Q scan when CTA cannot be done; the pathway is gated by pretest probability using the Wells criteria.
- Management
First, classify severity by hemodynamic status, since this dictates the sequence: massive PE (sustained hypotension, obstructive shock, or arrest) needs immediate thrombolysis; submassive PE (RV…
- Complications
Obstructive shock and cardiac arrest from acute RV failure in massive PE, the most immediately life-threatening complication.
- Prognosis
Risk is stratified primarily by hemodynamic status at presentation: massive PE with shock carries the highest short-term mortality; low-risk PE (sPESI 0) has an excellent prognosis, with outpatient management as safe as hospitalization.
- Prevention
Assess every hospitalized patient for VTE risk and provide pharmacologic prophylaxis unless contraindicated: enoxaparin 40 mg SC once daily (30 mg if creatinine clearance <30 mL/min), or…
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