Understanding Pulmonary Embolism: A Junior Doctor’s Guide

Pulmonary embolism (PE) can be a daunting diagnosis, but with a systematic approach, it becomes more manageable. As a junior doctor, understanding how to efficiently assess, investigate, and manage PE is crucial. This blog post will guide you through the essential steps, from history taking to management, based on the Oxford Handbook of Emergency Medicine and other reliable sources.

History Taking: Key Questions

• Risk Factors: Start by assessing the patient’s risk factors for PE. Ask about:

  • Recent Surgery or Trauma: Any recent operations, particularly orthopedic or pelvic surgeries?

  • Immobility: Have they been immobile or on long-haul flights recently?

  • History of Deep Vein Thrombosis (DVT) or PE: Any previous occurrences?

  • Medications: Are they on anticoagulants or have they recently stopped them?

  • Cancer: Any history of malignancy?

• Symptoms: Explore their presenting symptoms:

  • Chest Pain: Ask if it’s sharp, pleuritic, or associated with breathing difficulties.

  • Dyspnea: Is there sudden shortness of breath or worsening over time?

  • Cough: Any hemoptysis (coughing up blood)?

  • Syncope: Any recent episodes of fainting or near-fainting?

  • Leg Symptoms: Any swelling, pain, or redness in the legs?

• General Health: Gather information on:

  • Previous Health Issues: Any history of heart or lung disease?

  • Vital Signs: Document vital signs including temperature, heart rate, respiratory rate, and blood pressure.

Physical Examination: What to Look For

• General Inspection:

  • Signs of Distress: Look for signs of respiratory distress or anxiety.

  • Cyanosis: Check for any bluish discoloration of lips or extremities.

• Cardiovascular Examination:

  • Heart Sounds: Listen for abnormal heart sounds or a third heart sound (S3), which may indicate right heart strain.

  • Jugular Venous Pressure (JVP): Elevated JVP might suggest right heart failure or strain.

• Respiratory Examination:

  • Breath Sounds: Listen for abnormal breath sounds such as crackles or wheezes.

  • Examination of the Chest: Note any asymmetry or decreased breath sounds.

• Lower Limb Examination:

  • Swelling and Tenderness: Assess for signs of DVT, which can be a source of PE.

Investigations: What to Order

• Initial Testing:

  • D-Dimer: Elevated levels suggest the presence of clotting but are non-specific. This test is helpful if the probability of PE is low.

  • ECG: Look for signs of right heart strain or other abnormalities.

• Imaging Studies:

  • CT Pulmonary Angiography (CTPA): The gold standard for diagnosing PE. It provides detailed images of the pulmonary arteries.

  • Ventilation-Perfusion (V/Q) Scan: An alternative if CTPA is contraindicated. It assesses the distribution of air and blood flow in the lungs.

• Other Tests:

  • Ultrasound of the Legs: If DVT is suspected, it can help identify clot sources.

  • Arterial Blood Gas (ABG): To assess oxygenation and acid-base status, although it’s less specific for PE.

Management Plan: What to Do

• Immediate Management:

  • Stabilization: Ensure the patient is stable, monitor vital signs, and provide supplemental oxygen if needed.

  • Anticoagulation: Start anticoagulant therapy promptly to prevent further clot formation. Common choices include low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban.

• Advanced Management:

  • Thrombolysis: Consider if the patient has a massive PE with hemodynamic instability. Thrombolytic agents like tissue plasminogen activator (tape) can dissolve clots but carry a risk of bleeding.

  • Surgical Intervention: In extreme cases, surgical embolectomy may be required, especially if thrombolysis is contraindicated or ineffective.

• Follow-Up:

  • Monitoring: Regularly monitor for any complications or signs of recurrence.

  • Long-Term Management: Discuss long-term anticoagulation therapy with a specialist if needed, and consider secondary prevention strategies.

Final Thoughts

Diagnosing and managing pulmonary embolism involves a thorough history, careful physical examination, appropriate investigations, and prompt treatment. By following these structured steps, you’ll be better equipped to handle this critical condition and provide effective care to your patients. Always consult with senior colleagues and specialists as needed, and remember that a systematic approach is your best tool in emergency medicine.