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Suspected Pulmonary Embolism (Initial Approach)
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Stabilize, check anticoagulation contraindications, then risk-stratify.
Decision
Outcome
Decision
Suspected PE. First steps?
✓
Stabilize with O₂ + IV fluids if needed
✗
CTPA before checking for contraindications
Decision
Absolute contraindications to anticoagulation?
✓
Present → IVC filter + obtain diagnostic test
✓
None → use Wells score
Outcome
IVC filter + diagnostic imaging once stable
Decision
Modified Wells score result?
✓
PE unlikely (Wells ≤4)
✓
PE likely (Wells >4)
Decision
PE unlikely — next test?
✓
Age-adjusted D-dimer (×10 if >50 yr) or PERC
✗
CTPA on every patient
Decision
Diagnostic test result?
✓
Positive for PE → start/continue anticoagulation; thrombolytics if massive PE
✓
Negative → stop anticoagulation; pursue alternative diagnosis
Outcome
Anticoagulation (DOAC preferred unless cancer-related or pregnant); thrombolytics for hemodynamic instability
PESI score guides outpatient vs inpatient management.
Outcome
Look for other diagnoses (ACS, pneumothorax, pneumonia, pericarditis, MSK)
Decision
PE likely — next step?
✓
Empiric anticoagulation + CTPA (or V/Q if contrast contraindicated)
✗
D-dimer
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