Mount Carmel Health Partners Clinical Guidelines Pulmonary Embolus | Page 2

The main benefit of performing a Chest x-ray in evaluating a patient for suspected pulmonary embolism is to evaluate for alternative cause of symptoms
such as pneumothorax. While chest x-rays are normal up to twenty-five percent of patients, indirect findings of a pulmonary embolus include Fleischner
sign; distended central pulmonary artery due to presence of a large clot, Westermark Sign; oligemia distal to the embolism, Hamptom hump;
wedge-shaped consolidation of the involved lung tissue reflecting pulmonary infarct or Fleischner lines, which are long bands of focal atelectasis seen in
pulmonary infarcts.
CT pulmonary angiography with a sensitivity of 83% and a specificity of 96% is commonly used to evaluate patients at high risk for pulmonary embolism
showing no signs or symptoms of PE, may not warrant further testing per the clinical decision rule and the disease can be safely excluded with lower
extremity compression ultrasound.
Moderate to High Probability
Obtain CXR
 Hemodynamically stable?

No
Yes
Bedside Echocardiogram:
 RV Dilatation
 Septal Shift
 Right Heart Thrombus
Perform CT pulmonary angiogram (CTPA) or
VQ Scan
Negative CTPA or
Negative VQ scan in
medium risk patient
Present
Not Present
IV Fluids &
Resuscitate
PE Excluded
Admitted to ICU &
Anticoagulate
Positive CTPA or
Moderate or
High Probability
VQ Scan
Negative CTPA in
high risk patient or
Low Probability or
Intermediate VQ
scan
IV Fluids &
Resuscitate
PE Confirmed:
Treat unfractionated or
fractionated heparin
lower extremity compression ultrasound
Is patient stable
for further
evaluation of
PE?
Negative for DVT
DVT Excluded:
Consider other diagnosis
Pulmonary Embolus 2
Positive for DVT
DVT Confirmed:
Treat unfractionated or
fractionated heparin