Controversies in the Management of Acute Pulmonary Embolism in the Emergency Department

Abstract

Background: Acute pulmonary embolism (PE) is frequently diagnosed in the Emergency Department (ED), and the management approach can be nuanced.

Objective: In this narrative review, we synthesize the literature in selected areas of ongoing controversy regarding the diagnostic and management approaches for acute PE in the ED, and provide evidence-based recommendations to empower emergency physicians (EPs) to provide optimal care in these situations.

Discussion: d-Dimer is used to clinically exclude the diagnosis of PE patients who are stratified as low risk. However by utilizing likelihood ratio and with certain scoring tools, patient historically considered moderate or high risk for PE may safely be able to have the diagnosis excluded with a negative d-dimer. Traditional risk stratification and management strategies can be cautiously applied to patients with concomitant Coronavirus-19 infection while awaiting more definitive studies. There is an increasing trend in the diagnosis of isolated subsegmental PE, and many patients receiving this diagnosis may be treated without anticoagulation provided that they have no evidence of associated deep vein thrombosis (DVT) and can be closely followed as an outpatient. There is a persistent hesitancy to discharge patients with newly diagnosed acute PE, and existing well-supported risk stratification tools and clinical decision frameworks can support the EP's decision to safely discharge low-risk patients.

Conclusion: tThis review of the literature empowers emergency clinicians to manage challenging PE cases in the ED.

Keywords: COVID-19; emergency medicine; pretest probability; pulmonary embolism; subsegmental PE.