Pulmonary Embolism: The Clot Thickens, Part 1

Pulmonary
Written By Rachel F
 
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30% of Americans who have DVTs end up having long term complications. 100,000 people in America die from PEs every single year, 30% of those die within 30 days of diagnosis and 1/4 of people that present with PE sudden death is the very first symptom

Beginning your Work Up

 
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risk factors

Virchow’s Triad

  • Venous Stasis: long plane rides, ventricular dysfunction, venous insufficiency (PVD), previous clot already there

  • Hypercoagulability: pregnancy, cancer, estrogen therapy, thrombophilia, acute inflammatory disorders (i.e. sepsis)

  • Endothelial Injury: surgery, trauma, blood draws, atherosclerotic disease

Unilateral leg swelling

Unilateral leg swelling

DVT

  • Telltale sign: unilateral swelling - it’s going to be “swole”

  • The most sensitive exam is measuring the calf; 10cm down from tibial tuberosity, measure across - if there is a discrepancy of 3cm its very sensitive and specific for DVT

Deep Veins vs. Superficial Veins

  • Deep Veins LE: popliteal, common iliac, posterior and anterior tibial, superficial femoral, external iliac

Work-up

  • Pretest probability: you have some index of suspicion that the patient has a disease (e.g. you aren’t ordering CTAs on all your acute bronchitis patients)

  • Once you are suspicious for PE:

    • Calculate Wells Score (separate calculation for PE or DVT): you will get low, moderate, or high risk for PE

      • If you are moderate or high risk of VTE - your pre-test probability is high enough for PE that you need to test for something to rule it out. Back in the day that was a d-dimer (sensitive but not specific) - now we look at PERC criteria

      • If all the PERC criteria are negative, your pre-test probability for PE is less than 1%. That’s better than d-dimer

        • A way to remember PERC criteria - use the mnemonic HADCLOTS

          • Hormone use, age >= 50, DVT or PE history, coughing up blood, leg swelling, O2 sat<95%, tachycardia, surgery

  • If they are moderate/high risk on wells criteria and they failed PERC criteria, THEN you order d-dimer

    • If this is positive hen you consider additional testing/imaging modalities

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Rachel F

Rachel is a physician assistant who has been holding down the ICU since 2016. She joined the Pulmcast podcast in 2017 and has been hooked on FOAMed ever since. Rachel has a passion for teaching using technology with a special focus on preserving dignity in the ICU. When she's not at work, you’ll find her playing with her golden retriever, hunting for thrift store treasures, and soaking up time with her husband and son.

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