Gossage proposed a clinical algorithm for evaluating a patient suspected of having a massive pulmonary embolism.
Parameters:
(1) patient’s clinical condition
(2) clinical suspicion for pulmonary embolus
(3) imaging study findings
Clinically Stable
Suspicion |
Imaging Studies |
Management |
any |
VPS high probability |
treat for massive PE |
any |
VPS nondiagnostic |
perform alternative test |
high |
VPS normal |
perform alternative test |
low or intermediate |
VPS normal |
pursue other diagnosis |
where:
• 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).
Clinically Unstable
Transthoracic Echocardiogram or PA Catheterization |
Imaging Studies |
Management |
right ventricular overload |
transesophageal echocardiogram shows clot |
treat for massive PE |
right ventricular overload |
transesophageal echocardiogram negative |
consider further testing |
normal |
|
consider further testing or pursue other diagnosis |
other diagnosis |
|
treat other disorder |
where:
• PA = pulmonary artery
• If the clinical suspicion was high I would include alternative tests for pulmonary embolus if further testing is recommended.
Specialty: Pulmonology
ICD-10: ,