Pulmonary Embolism

Gestalt less than 15% + PERC (-) = PE is ruled out
Gestalt less than 40% + D-dimer (-) = PE is ruled out
Well's less than 4 + D-dimer (-) = PE is ruled out

• Immobilization risk: 6 hours of knee bent
• Surgery risk: intubated surgery the past 4 weeks
  
• D-dimer: 94% Sn, 55% Sp
• CTA: 90% Sn, 90% Sp
  - 8% Contrast Nephropathy (20% increase in creatinine)
• VQ scan accurate if non smoker and no long issues (like COPD)
  
• Pregnancy: highest risk is one week postpartum
  - adjust D-dimer: 750, 1000, 1250 for T1/T2/T3
  - plus PERC rule (adjust heart rate to 105/min)
  
  
• Submassive PE: PE without hypotension; controversial if needs to be lysed
• Indications for fibrinolysis:
  
  1. Hypotension (SBP less than 90 or drop of 60 from baseline)
     
  2. Respiratory Failure
  3. RV strain evidence that will damage the patient permanently
     - controversial, for those active/athlete patients
• Prognosticators
  
  1. Troponin T
  2. BNP: best (more than 90 pg/mL), will have significant RV strain in 6 months
  3. Echo
  4. Size of embolus?? poor correlation of outcome
     
     
• Fibrinolytics
  
  1. Alteplase 100mg over 2 hours, stop heparin
  2. Tenecteplase bolus (Not FDA approved)
     

*Gestalt: German word, the sum of its parts is not equal to the whole; Clinical Gestalt, ability to put the whole picture together which cannot be done by mathematical formula; whether a patient has high or low pretest probability; gift to every physician.