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

Abstract

Backgroundacute pulmonary embolism is frequently diagnosed in the Emergency Department, 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 pulmonary embolism (PE) in the Emergency Department, and provide evidence-based recommendations to empower emergency physicians to provide optimal care in these situations. DiscussionD-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 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 emergency physician's decision to safely discharge low-risk patients. Conclusion: this review of the literature empowers emergency clinicians to manage challenging PE cases in the ED.