=====Pulmonary Embolism=====
===Clinical===
  *may be asymptomatic
  *SOB, cough +/- haemotypsis
  *pleuritic chest pain
  *associated leg pain/swelling, signs of DVT
  *massive PE - central cyanosis, altered/LOC, collapse or shock

  * tachypnoea, tachycardia, hypotension
  * elevated JVP, parasternal heave, loud P2
  * <wrap em>Fever is common in PE</wrap> and can occur in ≥25% patients

  *clinical categorisation to direct Mx:
    *massive (high risk)- shock, persistent brady or asystole
    *sub-massive (intermediate risk) - evidence of RV dysfunction but no signs of shock
    *low risk - no evidence of RV dysfunction or shock

===Investigations==
  *ECG - often normal
    *sinus tachycardia
    *signs of R heart strain -SI, QIII, TIII (probably <10%), non-specific ST changes or TWI in anterior leads, right axis deviation, S wave (I and aVL) > 1.5mm, Q in III and aVF, P pulmonale & RBBB
  *ABG - hypoxia. Repeat after exercising may enhance diagnostic workup. Resp alkalosis. Metabolic acidosis if shock
  *CXR - only to rule out other pathology
  *CTPA - may not pick up smaller emboli
  *[[wiki:labs#procalcitonin|PCT]] may be useful as usually raised in bacterial infections but not PE

===Management===
  *Low molecular weight heparin (LMWH)
  *Fondaparinux.
  *Unfractionated heparin.
  *Oral anticoagulants: Warfarin, apixaban, or rivaroxaban. {{ :wiki:respiratory:cuh-doacs-in-adults-with-dvt-pe-and-vte-guidelines.pdf |CUH DOACs for VTE}}
  *LMWH followed by an oral anticoagulant (dabigatran or edoxaban)
  *Thrombolysis - only for massive. Debate continues about their place in sub-massive
    *plasminogen activators - fibrin specific rt-PA or non selective agents - streptokinase, urokinase 
  *IVC filters and embolectomy

^:::^Streptokinase ^Urokinase ^Alteplase ^Reteplase ^Tenecteplase |
| |activate systemic plasminogen, which is not part of the clot matrix\\ hydrolyses fibrin of thromboemboli, causing clot lysis ||preferentially activate plasminogen on clot surface.\\ Classified as fibrin specific |||
^Generation |1st |1st |2nd |3rd |3rd |
^Clot-specific? |No |No |Yes |Yes |Yes |
^Half-life (mins) |12 |7–20 |4–10 |11–19 |15–24 |

====Risk factors investigation====
if no obvious cause of embolic disease is found, hypercoagulation investigation should follow:
  *Antithrombin III deficiency
  *Protein C or protein S deficiency
  *Lupus anticoagulant
  *Homocystinuria
  *Occult neoplasm
  *Connective tissue disorders

====Wells criteria====
^  Wells criteria for PE  ||
|clinical signs and symptoms of DVT  ^  3  |
|alternative diagnosis is less likely than PE  ^  3  |
|HR >100  ^  1.5  |
|immobilisation ≥3 consecutive days or surgery in the previous 4/52  ^  1.5  |
|previous objectively diagnosed PE or DVT  ^  1.5  |
|haemoptysis  ^  1  |
|malignancy (on Rx, or in last 6/12 or palliative)  ^  1  |
| ^0-1: low risk\\ 2-6: moderate risk\\ >6: high risk|

====PESI (Pulmonary Embolism Severity Index)score====
^Age | Age in years |
^Male sex |10 |
^Cancer |30 |
^Heart Failure |10 |
^Chronic lung disease |10 |
^Pulse ≥ 110/min |20 |
^sBP < 100 mm Hg |30 |
^RR ≥ 30/min |20 |
^Temperature < 36°C |20 |
^Altered mental status |60 |
^PaO2 sat < 90% (+/-O2 Rx) |20 |
<alert shadow>Risk and Mx strategy:</alert>
^score ||
^≤ 65 | Class I, Very Low Risk |discharge on oral anti-coag |
^66-85 | Class II, Low Risk |discharge on oral anti-coag |
^86-105 | Class III, Intermediate Risk |potential for decompensation\\ probable admission for Ix and monitoring |
^106-125| Class IV, High Risk |admission |
^> 125| Class V, Very High Risk |admission |
===Resolution and monitoring===
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646369/|Rate of resolution of thrombus in PE measured by CTPA]]\\ 
[[https://www.ajronline.org/doi/10.2214/AJR.09.3410|resolution of PE thrombus]]

==References include:==
[[https://cks.nice.org.uk/topics/pulmonary-embolism/management/confirmed-pulmonary-embolism/|NICE PE 2020]]\\ 
https://litfl.com/pulmonary-embolism/\\ 
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5132419/|PE Thrombolysis review 2016]]\\ 
[[https://journals.sagepub.com/doi/10.1177/1076029610375425|Procalcitonin in PE and pneumonia 2010]]\\ 
{{ :wiki:respiratory:2014_esc_guidelines_on_the_diagnosis.pdf |2014 ESC guidelines Dx and Mx of PE}}\\ 
{{ :wiki:respiratory:2016_chest_guideline_-_antithrombotic_rx_for_vte_disease.pdf |2016 CHEST antithrombotic Rx for VTE}}\\ 
[[https://thorax.bmj.com/content/73/Suppl_2/ii1|Initial OP Mx of PE - BritThorSoc 2018]]\\