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PE Workup in 5 Steps

September 8, 2018

Written by Clay Smith

PE Workup in 5 Steps

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This figure is a composite of the great ideas of others, with some adaptation on my part.  The following is a list of the resources that went into making this figure.  I’m standing on their shoulders.

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8 thoughts on “PE Workup in 5 Steps

    • To clarify, some recommend unfractionated heparin (UFH) in "intermediate" risk PE, aka submassive PE, because they have risk of becoming unstable and may need tPA. These are patients with RV dysfunction. In my diagram I have two categories of "intermediate" risk: those with non-low PESI + no RV dysfunction and those with RV dysfunction. If no RVD, there is no need for UFH. But those with RVD have about a 5% chance of clinical decompensation (per PEITHO). So one could argue that PE patients with RVD who are not hemodynamically unstable should be started on UFH so it could be turned off if they developed hemodynamic instability and tPA was started. Truly unstable PE, defined as SBP </= 90 or drop in SBP by 40 from baseline for 15 minutes, should get tPA.

    • This would be either Well’s score or revised Geneva score. You dichotomize either by grouping low/intermediate pretest probability as Decision Rule Unlikely; high pretest probability = Decision Rule Likely. Or you could use a simplified Well’s that dichotomizes PE Likely or PE Unlikely. That is my personal favorite.

  • Why PERC before Wells? I’ve been taught to make sure patient is low risk on Wells before using PERC. Can you clarify this?

    • There is debate about this. In the PERC study, it was true physician gestalt. They were not instructed to use a structured decision instrument to determine whether or not to consider them low. So in keeping with the PERC study, I put it first. Only if not "gestalt low" or "PERC+" do I then quantify my gestalt – and that is to determine whether I should do a D-dimer or go straight to CTPA. This is also the order presented in a recent review by the PE gurus: J Thromb Haemost. 2017 Jul;15(7):1251-1261. doi: 10.1111/jth.13694.
      Diagnosis of acute pulmonary embolism.
      Here is my caveat. All these people get an ECG in my ED. I hold on my clinical gestalt judgment on whether or not to use PERC until after I look at the ECG. Here I am in the realm of opinion, so take that with a grain of salt. It would not be wrong to use a decision rule like Well’s or Geneva prior to PERC. I just like how PERC takes into consideration true gestalt. If I say to myself, "I don’t think they really have a PE," then I will use PERC. If I say, "Hmmm…I’m not sure…they might," then I don’t. In the original PERC study, "low gestalt" was defined as thinking they had <15% chance of PE.

  • In the quantify gestalt step – what Well Score cut off are you using to define "Decision Rule Unlikely" and then proceeding to a D-Dimer. Seem like there should be a third arm. If the Decision rule is unlikely (for ex Wells Score = 0) – then no further workup required but if Decision Rule is given you an moderate risk then there is a third arm.

    Bottom line – what Wells Score gray zone – do you get a D-Dimer

    • You can use Well’s or revised Geneva as three categories: low, intermediate, and high. But it’s much simpler to dichotomize the results by lumping together low/intermediate. Either way, it does not affect diagnostic performance. See https://www.ncbi.nlm.nih.gov/pubmed/21646554. Also for both scores, there is a simplified version that dichotomizes results, which was also just as good as splitting into 3 pretest probability categories. So, you can choose to use either the simplified, dichotomized versions or the original versions and lump low/intermediate as "PE Unlikely" and high as "PE Likely". To answer your question very specifically, anyone with a low to intermediate pretest probability on Well’s or revised Geneva gets a D-dimer (age adjusted). If negative, PE is excluded. If positive, CTPA. The one I use in practice is the simplified Well’s with Unlikely or Likely dichotomous result: ≤4 = Unlikely; >4 = Likely. Thankfully, we have MDCalc. https://www.mdcalc.com/wells-criteria-pulmonary-embolism

What are your thoughts?