Postoperative Pulmonary Emboli
The first step in evaluation of a patient with possible pulmonary embolism is history and physical examination. Presenting symptoms for pulmonary emboli are often nonspecific and can range from an asymptomatic presentation to fever, dyspnea, hypotension, tachypnea, or unexplained tachycardia. Chest pain may develop acutely or worsen over several days. Immediate empiric treatment is determined by patient stability and contraindications to anticoagulation and/or thrombolysis. Hemodynamically unstable patients require immediate therapeutic anticoagulation and consideration of thrombolysis or thrombectomy. Stable patients can undergo further diagnostic evaluation based on clinical suspicion and availability of resources. The Wells prediction scoring system is commonly employed to categorize patient risk for thrombus formation. Patients with moderate to high probability for PE can progress to imaging such as CT angiography or ventilation-perfusion radionuclide scanning. Patients who have low probability and not subject to recent surgery, trauma, or who are pregnant can be evaluated with a D-dimer assay. Although a positive D-dimer test is often nonspecific, it can be a useful diagnostic tool in combination with clinical probability. Treatment for pulmonary embolism is dependent on anticoagulation contraindications and patient stability. Treatment consists of therapeutic anticoagulation to prevent clot propagation. If the patient is hemodynamically unstable, catheter-directed thrombolysis may be indicated and potentially thoracotomy with thrombectomy. Patients unable to be anticoagulated or undergo thrombolysis may need temporary inferior vena cava (IVC) filter placement.
KeywordsPulmonary embolism Deep venous thrombosis Wells score D-dimer CT angiography Ventilation-perfusion scan Anticoagulation Thrombolytic therapy Embolectomy Thoracotomy IVC filter