22 Jul - Pulmonary Embolism

This AMs case was a patient admitted with subacute onset of dyspnea.  Initial evaluation revealed an elevated D-dimer, swollen LLE and normal CXR.  CT PE study revealed extensive bilateral PEs with proximal involvemetn and R heart strain.  He had made several recent long car trips but had no other known predisposition to thromboembolism. 

For a recent summary of acute PE management see this NEJM review from this past week's issue.

Regarding selection of PE patients for outpatient treatment or early discharge - know that the data to support this practice is of poor quality and that patients with hypoxemia, RV dysfunction, large proximal PEs, and obesity (>110 kg) were excluded from the studies of outpatient treatment.  These individuals should be managed as inpatients until oral anticouagulants are at therapeutic levels and clinical stability is achieved.  This recent review should be noted before you consider early discharge of a PE patient.