Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Lower extremities DVT found in 70% of patients with PEPE is life-threatening in critically ill patients with a 30% mortality rate +++ Clinical Assessment ++Table Graphic Jump Location|Download (.pdf)|PrintModified Geneva ScoreFactorPointsAge ≥651Surgery/fracture within 1 month2Active malignancy2Hemoptysis2Previous DVT or PE3Unilateral lower limb pain3HR 75–943HR ≥955Pain on deep palpation of lower limb, unilateral edema4Probability of PE: 0–3 points: low probability (8%)4–10 points: intermediate probability (28%)≥11 points: high probability (74%)++ High index of suspicion: Any patient with immobilization with above symptoms should be evaluatedIntraoperative or postoperative: long bone fracture repair with unexplained symptoms should be evaluated for fat emboliComplicated vaginal or Cesarean delivery patients evaluated for amniotic fluid embolization +++ Diagnostic Tests ++ EKG: classic signs of right heart strain demonstrated by an S1–Q3–T3 pattern (Figure 206-1) are observed in only 20% of patients with proven PEArterial blood gas shows slight alkalosis and raised alveolar–arterial oxygen gradientIncreased cardiac markers (BNP, troponin T and I): suggest RV strain; perform echo; discuss thrombolysis ++Figure 206-1. Classic EKG Pattern in PEGraphic Jump LocationView Full Size||Download Slide (.ppt)S wave is apparent in lead I (blue arrowhead), Q wave in lead III (black arrowhead), and inverted T wave in lead III (blue arrow). Reproduced from Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. Figure 23-47B. Available at: http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. +++ Imaging ++ Chest x-ray: usually normal in PE, occasional atelectasis, consolidation, and elevated hemidiaphragm with lung infarcts seenCT angiography (CTA) is the initial imaging modality of choice for stable patients, sensitivity 96–100%, specificity 89–98%Ventilation–perfusion (V/Q) scans should be used only when CT is not available or if the patient has a contraindication to intravenous contrast; only useful if normal chest x-ray. Preferable if pregnancy (controversial)Lower extremities Doppler ultrasound to rule out DVTEchocardiography: may demonstrate right ventricular dysfunction in acute PE, predicting a higher mortality and possible benefit from thrombolytic therapy. TEE can visualize large thrombus in pulmonary artery ++Figure 206-2. Algorithm If Clinical Suspicion of PEGraphic Jump LocationView Full Size||Download Slide (.ppt) +++ Initial (O2, Vasopressors If Needed) ++ Anticoagulation (AC) reduces mortality and is considered a primary therapy for PE: Empiric AC is considered if index of suspicion is high and no contraindication, IV heparin, SC LMWH, or SC fondaparinux can be started before diagnosis is confirmed AC reduces the mortality rate of PE because it slows or prevents clot progression and reduces the risk of further embolismPrompt effective AC ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth