EM. R1 박정숙

Purpose Formulate comprehensive recommendations for the diagnostic approach to patients with suspected pulmonary embolism, based on randomized trials.

Methods Based on results of Prospective Investigation of Pulmonay Embolism Diagnosis II (PIOPED II) Outcome study

Diagnostic test Clinical probability of pulmonary embolism Condition of the patient Availability of diagnostic test Risks of iodinated contrast material Radiation exposure cost

D-dimer assay

Allergy to iodinated contrast material D-dimer with clinical assessment Treated with steroids before the CT imaging Venous ultrasound and pulmonary scintigraphy Serial venous ultrasound and gadoliniun-enhanced cT angiography are option

Impaired renal function D-dimer with clinical assessment Venous ultrasound Pulmonary scintigraphy Serial venous ultrasound is option

Womans reproductive age D-dimer rapid ELISA Venous ultrasound Pulmonary scintigraphy (minimized breast radiation) CT angiogram with venous ultrasoud is alternative CT venogram: start at the acetabulin to reduce gonadal irradiation

Radiation exposure

Pregnant patients D-dimer Venous ultrasound before imaging test with ionizing radiation (13%~15%) Pulmonary scintigraphy CT angiogram ->Ventilation/perfusion scans are rcommended

Patients in Extremis Bedside echocardiography and lge ultrasonogray (RV enlargement or poor RV function) Venous ultrasound Portable perfusion scan Transfer to an interventional catheterization laboratory

Conclusion The sequence for diagnostic test in patients with suspected pulmonary embolism depends on the clinical circumstaces

Conclusion Negative D-dimer with low or moderate probability clinical assessment can safely exclude pulmonary embolism Not excluded, CT angiography/CT venography is recommend Further evaluation depends on clinical judgement