0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:19
1242 Pulmonary Embolism➣Normal V/Q essentially rules out PE
➣High prob V/Q: highly likely PE (unless prior PE or low suspicion)
➣Low prob V/Q & low suspicion: consider other diagnosis (nega-
tive leg US adds confidence to “no PE” diagnosis)
■Low prob V/Q & suspicion not low, or intermediate prob V/Q:
➣consider spiral CT, treat if+
➣consider leg US, treat if+
if negative, consider angiogram or
if patient stable, suspicion not high, & adequate cardiopul-
monary reserve, consider serial leg studies over following week.
If leg studies remain neg, low risk of subsequent PE
■Evaluate for thrombophilia if age <50, family history, or recurrent
thrombosisspecific therapy
Treatment Options:
■Weight-based unfractionated (Usual type) heparin
➣check for contraindications
➣baseline PT/INR, PTT, CBC
➣daily platelet count
➣PTT 4–6 hours after starting heparin & q6 hours 24 hours, then
qAM unless out of therapeutic range
➣Minimum 5 days, overlap with warfarin until INR 2.0–3.0×2 days
➣Complications:
Bleeding
Thrombocytopenia
Hypersensitivity reactions
Osteoporosis with use >6 months
➣Contraindications:
Absolute: Hypersensitivity; thrombocytopenia; history of
heparin induced thrombocytopenia; uncontrolled bleeding;
intracranial hemorrhage
Relative: bleeding disorders; GI bleeding or ulcer; severe liver
disease; uncontrolled hypertension; recent surgery; need for
invasive procedures
■Low molecular weight heparin (LMWH)
➣check for contraindications to heparin
➣baseline PT/INR, PTT, CBC
➣platelet count q2 days
➣Minimum of 5 days, overlap with warfarin until INR 2.0–3.0×^2
days