Key Points

Clinical decision rules using objective scoring algorithms help establish pretest probability and enhance the predictive value of other tests for pulmonary embolism (PE). A negative quantitative D-dimer test by ELISA less than 500 pg/L can effectively rule out PE in patients with low or intermediate pretest probability of disease.

• High-resolution CT scan with contrast can be performed on the lungs and the deep veins of the legs at the same time in a PE protocol.

• Hemodynamically stable patients with submassive PE may be treated with dose-adjusted intravenous or fixed-dose subcutaneous heparin.

• Hemodynamically unstable patients with massive PE may be treated with thrombolytics or embolectomy.

• Prophylactic therapy is not effective if initiated after a clot has begun to form, so venous thromboembolism prophylaxis with subcutaneous heparin should be part of standard hospital admitting orders unless specifically contraindicated.

In the 19 th century, Rudolf Virchow defined the pathologic process of pulmonary embolism, in which blood clots, usually from deep vein thromboses (DVTs) in one or both legs, break off and are trapped in the pulmonary arterial system, leading to pulmonary infarct, decreased oxygenation of venous blood returning from the periphery, and elevated right-sided pressures in the heart (Dalen, 2002). Two thirds of emboli reach both lungs and lodge in large or intermediate pulmonary arteries, most often in the lower lobes.

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