Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach

Area of Science:

• Emergency Medicine
• Diagnostic Imaging
• Cardiology

Background:

• Part 1 of this review discussed risk factors for pulmonary embolism (PE) in emergency department (ED) patients.
• Symptomatic ED patients present unique challenges for PE diagnosis.

Purpose of the Study:

• To describe evidence-based criteria for excluding and diagnosing PE.
• To guide clinicians in the diagnostic process for suspected PE.

Main Methods:

• Review of published evidence on PE diagnostic criteria.
• Analysis of clinical and radiographic features associated with missed PE diagnoses.
• Evaluation of D-dimer utility and computed tomographic pulmonary angiography (CTPA).

Main Results:

• Clinical criteria, including gestalt and PERC rule, can safely obviate PE evaluation in many ED patients.
• D-dimer testing can exclude PE in numerous cases, with age-adjusted thresholds reducing unnecessary imaging.
• Algorithms are presented to guide PE exclusion and diagnosis, including in pregnant patients.

Conclusions:

• Emergency clinicians can exclude PE in many symptomatic ED patients using clinical judgment alone.
• D-dimer testing further enhances the ability to rule out PE, minimizing exposure to pulmonary vascular imaging.
• The review provides practical algorithms for PE diagnosis and exclusion in diverse patient populations.