Gossage proposed a clinical algorithm for evaluating a patient suspected of having a massive pulmonary embolism.
(1) patient’s clinical condition
(2) clinical suspicion for pulmonary embolus
(3) imaging study findings
VPS high probability
treat for massive PE
perform alternative test
low or intermediate
pursue other diagnosis
• VPS indicates ventilation perfusion scan.
• Alternative tests include pulmonary angiography, spiral CT angiography, and lower extremity Doppler.
NOTE: I have modified the algorithm slightly to include additional studies if a high clinical suspicion is present and the ventilation-perfusion scan is normal. This was based on the editorial by Gallagher EJ in Annals of Emergency Medicine (2000; 35: 181-187).
Transthoracic Echocardiogram or PA Catheterization
right ventricular overload
transesophageal echocardiogram shows clot
transesophageal echocardiogram negative
consider further testing
consider further testing or pursue other diagnosis
treat other disorder
• PA = pulmonary artery
• If the clinical suspicion was high I would include alternative tests for pulmonary embolus if further testing is recommended.
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