OBJECTIVE
Establish a comprehensive and standardized hospital framework for the diagnosis, treatment, and management of pulmonary embolism (PE), aiming to improve quality of care, optimize resources, and reduce morbidity and mortality associated with this condition in the hospital setting.
SCOPE
All hospitalized patients over 15 years of age in our institution.
RESPONSIBILITIES
Institution physicians. Nursing staff.
REFERENCES AND BIBLIOGRAPHY
- SATI Guidelines for the Management and Treatment of Acute Thromboembolic Disease. Revista Argentina de Terapia Intensiva 2019 - 36 No. 4.
- Farreras-Rozman. Internal Medicine. 16th Edition. El Sevier. 2010.
- SAC Consensus for the Diagnosis and Treatment of Venous Thromboembolic Disease. Argentine Journal of Cardiology. October 2024 Vol. 92 Suppl. 6 ISSN 0034-7000
- 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). European Heart Journal (2020) 41, 543-603. doi:10.1093/eurheartj/ehz405
INTRODUCTION
Pulmonary embolism (PE) is a cardiovascular emergency caused by a blood clot, usually originating from the deep veins of the lower limbs, that travels to the lungs and obstructs the pulmonary arteries. This condition represents a significant cause of morbidity and mortality in hospitals. Timely diagnosis and treatment are essential to improve clinical outcomes.
The clinical presentation of PE is highly variable, ranging from mild symptoms to acute cardiovascular shock. Risk factors such as prolonged immobilization, recent surgery, and chronic illnesses complicate its identification and management.
PE has an annual incidence of 70 cases per 100,000 people. Prognosis varies from high-risk PE with high mortality to low-risk PE with minimal hemodynamic impact. Without thromboprophylaxis, deep vein thrombosis (DVT)—the main predisposing factor (90–95% of cases)—has variable incidence depending on the surgery type, and up to 25% of embolic events occur post-discharge.
PREDISPOSING FACTORS
Strong Risk Factors (OR >10):
- Hip or leg fracture
- Hip or knee prosthesis
- Major general surgery
- Major trauma
- Spinal cord injury
Moderate Risk Factors (OR 2–9):
- Arthroscopic knee surgery
- Central venous catheters
- Chemotherapy
- Chronic heart or respiratory failure
- Hormonal replacement therapy
- Malignancy
- Oral contraceptives
- Stroke with paralysis
- Pregnancy or postpartum
- Prior VTE
- Thrombophilia
Mild Risk Factors (OR <2):
- Bed rest <3 days
- Prolonged travel
- Advanced age
- Laparoscopic surgery
- Obesity
- Antepartum period
- Varicose veins
CLINICAL MANIFESTATIONS AND BASIC COMPLEMENTARY STUDIES
Symptoms: Dyspnea, chest pain, cough, hemoptysis, bronchospasm, fever.
Signs: Tachycardia, desaturation, jugular vein distention, orthostatism, DVT signs, syncope, or shock.
Signs: Tachycardia, desaturation, jugular vein distention, orthostatism, DVT signs, syncope, or shock.
Basic Studies:
- Chest X-ray (may show infarction or atelectasis)
- ECG (T wave inversion, RV strain, S1Q3T3 pattern)
RISK ASSESSMENT SCORES
Wells Score:
-
6 points: High probability
- 2–6: Moderate
- ≤2: Low
- Modified: >4 = likely PE, ≤4 = unlikely PE
Geneva Score:
-
10: High
- 4–10: Intermediate
- 0–3: Low
PERC Rule:
If all criteria are negative and clinical suspicion is low, PE can be excluded without further testing.
If all criteria are negative and clinical suspicion is low, PE can be excluded without further testing.
DIAGNOSTIC STUDIES
- D-dimer: High sensitivity; used in low/moderate risk patients.
- CT Pulmonary Angiography (CTPA): First-line imaging; limited in pregnancy/renal failure.
- Lower limb Doppler ultrasound: Indirect evidence of PE when DVT is detected.
- V/Q scan: Alternative when CTPA is contraindicated.
- Transthoracic echocardiogram: Used to assess RV function, especially in shock.
- Pulmonary angiography: Gold standard; reserved for complex cases due to invasiveness.
RISK STRATIFICATION
High-risk PE (5%): Hemodynamic instability, mortality >15%. Requires urgent reperfusion.
Intermediate-risk PE (30–50%): Hemodynamically stable with signs of RV dysfunction or elevated biomarkers.
Low-risk PE: Mortality <1%, eligible for outpatient management.
PESI Score:
- I (<65): Very low risk
- II (65–85): Low
- III (86–105): Intermediate
- IV (106–125): High
- V (>125): Very high
Simplified PESI: ≥1 point = high risk; 0 = low risk
TREATMENT
High-risk PE:
- Systemic fibrinolysis with alteplase 100 mg over 2 h or 0.6 mg/kg (max 50 mg) IV bolus over 15 min.
- Suspend UFH 30–60 min before lysis if already on treatment.
- Resume anticoagulation (UFH or LMWH) when aPTT <2x normal.
- Consider surgical embolectomy or catheter-directed therapy if fibrinolysis fails or is contraindicated.
- Maintain SpO₂ >90%, CVP 8–12 mmHg, and use vasopressors/inotropes as needed. ECMO in select cases.
Contraindications to Fibrinolytics:
- Absolute: Recent stroke, active bleeding, CNS tumors, recent major trauma or surgery.
- Relative: Anticoagulant use, recent TIA, pregnancy, uncontrolled hypertension, liver disease.
Intermediate-risk PE:
- Initiate anticoagulation (enoxaparin 1–1.5 mg/kg SC every 12 h, max 100 mg/dose).
- Fibrinolysis is not routine; reserve for clinical deterioration.
- Direct oral anticoagulants (DOACs) may be considered.
- Consider IVC filter in absolute contraindication to anticoagulation or recurrence despite treatment.
RIETE Bleeding Risk Score:
-
4 points: High risk
- 1–4: Intermediate
- 0: Low
INVASIVE TREATMENT
Consider catheter-directed therapy when:
- High bleeding risk
- Fibrinolysis contraindicated
- Delayed symptom onset >14 days
Some centers use this as first-line therapy in high-risk PE.
QUALITY INDICATOR
Indicator:
Proportion of PE cases with documented risk stratification in the medical record at initial evaluation.
Proportion of PE cases with documented risk stratification in the medical record at initial evaluation.
Formula:
(PE cases with documented stratification / total PE cases evaluated) × 100
(PE cases with documented stratification / total PE cases evaluated) × 100
Target: >85% of PE cases must have risk stratification recorded at the time of initial evaluation.
Autor
Kamo Weasel - MD Infectious Diseases - MD Internal Medicine - #DocChain Community @Kamo Weasel