The diagnostic pathway embolism: from the Emergency Department to the Internal Medicine Unit

Abstract

Symptomatic venous thromboembolism occurs in 1-2 per 1000 adults each year; a third of these patients present with pulmonary embolism, 1 which is the most common cause of vascular death after myocardial infarction and stroke. Symptomatic pulmonary embolism is thought to be rapidly fatal in 10% of cases, plus 5% after starting treatment. About 2% of pulmonary embolism patients develop thromboembolic pulmonary hypertension. 1,2 This is why the diagnostic pathway, both in the emergency unit and in the medical department, should be guided by two principles: i) a fast and accurate identification of patients affected, as a diagnostic delay might be fatal and a diagnostic mistake might increase the bleeding risk; and ii) a correct risk stratification, in order to choose the most appropriate treatment. 3,4 Diagnostic scores (Wells and Geneva) and principal markers for pulmonary embolism risk stratification (hypotension-shock, markers of right ventricular dysfunction or myocardial injury), together with the optimal radiological and laboratory testing [scintigraphy and computed tomography (CT) scan, D-dimer], can lead to a prompt diagnosis and address the patient to the most appropriate in-hospital pathway (discharge, admission or intensive care unit). We describe the diagnostic pathway, based on the evidence from literature, which we adopted in our hospital. DiscussionThe clinical presentation of acute pulmonary embolism varies widely among patients, depending on ABSTRACTThe diagnostic pathway of pulmonary embolism, both in the Emergency Department and in the Medical Unit, is not a standardized one. Pulmonary embolism, often but not always complicating surgery, malignancies, different medical diseases, sometimes but not often associated with a deep vein thrombosis, is not infrequently a sudden onset life-threatening and rapidly fatal clinical condition. Most of the deaths due to pulmonary embolism occur at presentation or during the first days after admission; it is therefore of vital importance that pulmonary embolism should promptly be diagnosed and treated in order to avoid unexpected deaths; a correct risk stratification should also be made for choosing the most appropriate therapeutic options. We review the tools we dispose of for a correct clinical assessment, the existing risk scores, the advantages and limits of available diagnostic instruments. As for clinical presentation we remind the great variability of pulmonary embolism signs and symptoms and underline the importance of obtaining clinical probability scores before making requests for further diagnostic tests, in particular for pulmonary computer tomography; the Wells score is the only in-hospital validated one, but unfortunately is still largely underused. We describe our experience in two different periods of time and clinical settings in the initial evaluation of a suspected pulmonary embolism; in the first one we availed ourselves of a computerized support based on Wells score, in the second one we did not. Analysing the results we obtained in terms of...