the classic S1,Q3,T3 with right axis deviation and right bundle branch block is uncommon
evidence of myocardial ischaemia
chest radiography occasionally show reduced vascular markings
blood gases show impaired gas exchange with arterial hypoxaemia and hypocapnia
pulmonary infarction causes an increased ESR
D-dimer - this is a highly sensitive but nonspecific test for diagnosing pulmonary embolism. A d-dimer below a certain cut point rules out PE with a high predictive value, at least in patients with a low or moderate clinical probability
ventilation-perfusion scan:
demonstrate areas of ventilation-perfusion mismatch
emboli are frequently multiple
the lower lobes are more frequently involved than the upper part of the lungs
CT pulmonary angiogram (CTPA) - generally performed for anybody with a clinically high risk for PE, or patients with low or moderate clinical risk and a positive D-dimer result. If a ventilation-perfusion scan is performed and the result is equivocal then CTPA should subsequently be performed
CT venography - a US review notes the combination of CTPA and CT venography increases the sensitivity of detection of pulmonary embolism (3)
Notes:
there is study evidence that clevated troponin levels identify patients with acute pulmonary embolism at high risk of short-term death and adverse outcome events (4)
study evidence revealed that CTPA was not inferior to V/Q scanning in ruling out pulmonary embolism (5)
however, significantly more patients were diagnosed with pulmonary embolism using the CTPA approach
a review examined the diagnostic process for pulmonary embolism (3):
state of the art of diagnostic evaluation of hemodynamically stable patients with suspected acute pulmonary embolism was reviewed
diagnostic evaluation should begin with clinical assessment using a validated prediction rule in combination with measurement of D-dimer when appropriate
sensitivity for detection of pulmonary embolism was increased by combining CT angiography (4-slice or 16-slice) with CT venography
methods to reduce the radiation exposure of CT venography include imaging only the proximal leg veins (excluding the pelvis) and obtaining discontinuous images. Compression ultrasound can be used instead
in young women, radiation of the breasts produces the greatest risk of radiation-induced cancer. It may be that scintigraphy (V/Q scan) is the imaging test of choice in such patients
patient-specific approach to the diagnosis of pulmonary embolism can be taken safely in hemodynamically stable patients to increase efficiency and decrease cost and exposure to radiation
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