GIM Question 40 Instructor

What are the Well’s criteria for pulmonary embolism?
Well’s criteria:

• Clinical signs of DVT (3 points)
• Alternative diagnosis less likely than PE (3 points)
• Heart rate >100bpm (1.5 points)
• Immobilization or surgery within 4 weeks (1.5 points)
• Previous DVT/PR (1.5 points)
• Hemoptysis (1 point)
• Malignancy with ongoing treatment or palliative (1 point)

Probability of PE based on score:

• <2 Low probability
• 2-6 Moderate probability
• >6 High probability

What investigations would you order for a suspected PE?
If there is a high suspicion of pulmonary embolism, a stat ECG, troponin, CK, and CT with pulmonary angiogram should be ordered.
What is your initial treatment for a PE?
Initial treatment for a pulmonary embolism includes:

• Supplemental O₂
• Anticoagulation (if hemodynamically stable)
  • Low molecular weight heparin
    • Enoxaparin 1mg/kg q12h or 1.5mg/kg daily for 5-10d
    • Tinzaparin 175U/kg daily for 5-10d
    • Dalteparin 100IU/kg q12h or 200IU/kg daily for 5-10d
    • Nadroparin 86 IU/kg q12h or 171 IU/kg daily for 5-10d
  • Fondaparinux is another option
• Thrombolysis (if hemodynamically unstable/massive PE)
  • tPA 100mg IV over 2hrs

Resources

1. Wells PS, Anderson DR and Ginsberg J. Assessment of deep vein thrombosis or pulmonary embolism by the combined use of clinical model and noninvasive diagnostic tests. Semin Thromb Hemost. 200;26:643-656.
2. Konstantinides SV et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35:3033-3073.