Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:19

Pulmonary Embolism 1241

➣<500 ng/ml may exclude; usefulness unclear, especially if malig-

nancy or recent surgery

ECG:

■anterior T wave inversions, tachycardia

■less common: new RBBB, afib

■massive PE: 30% with RBBB, P-pulmonale, RAD, or S1 Q3 T3

CXR:

■atelectasis or non-specific

■also: effusion, elevated hemidiaphragm, prominent PA, cardio-

megaly, focal oligemia (Westermark’s sign)

Imaging:

■V/Q scans

➣Normal essentially rules out PE

➣PE present in:

96% with high suspicion & high prob V/Q

87% with high probability V/Q

33% with intermediate probability V/Q

12% with low probability V/Q

4% with low suspicion & low prob V/Q

■Spiral CT (CT Angiogram)

➣Sensitivity 53 to 98%; greatest for main, lobar, & segmental arter-

ies

➣If neg & high suspicion, consider conventional angiogram

➣Risk of nephrotoxicity

■Doppler-Ultrasound

➣High yield for symptomatic DVT

➣Consider with non-diagnostic V/Q

➣Clot in “superficial femoral vein” is a DVT

■Angiogram

➣Diagnostic in 96%

➣Complication rate (death & major): 1.2%

➣Risk of nephrotoxicity

differential diagnosis

■Pneumonia, COPD, asthma, CHF, MI, pneumothorax, rib fracture,

pleurodynia

management

■Assess oxygenation, vital signs, risk factors

■If high suspicion, start heparin