PULMONARY EMBOLISM (PE), SUSPECTED ACUTE ALGORITHM

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1 PULMONARY EMBOLISM (PE), SUSPECTED ACUTE ALGORITHM Start Rm air pulse ximetry Cnsider supplemental xygen IV access and STAT CBC and DIC screen Urine β-hcg, if apprpriate CXR (PA + lateral), EKG and call the Cardilgy Fellw fr Ech review Review criteria* fr urgent imaging fr pssible PE based n age-specific risk factrs (see green bxes) Inclusin Criteria: Patient presents with suspected Pulmnary Emblism (PE) Exclusin Criteria N suspected PE < 18 years ld *Criteria fr Urgent Imaging: Patients < 18 years ld Painful leg swelling r knwn recent diagnsis f deep vein thrmbsis (DVT) Family r persnal histry f DVT r PE Knwn cltting disrder predispsing t DVT r PE Recent r current indwelling central venus catheter Elevated systemic estrgen (e.g., ral cntraceptive pill use, pregnancy) Recent immbility Recent majr r rthpedic surgery r trauma Acute r chrnic inflammatry cnditin Obesity Patient age? 18 years r lder *Criteria fr Urgent Imaging: Fr patients 18 years ld Please refer t the Wells Criteria Algrithm n page 7. N t ALL criteria Cnsider nn-urgent imaging fr PE, cnsider alternative diagnses Des patient meet 1 r mre criteria fr urgent imaging OR is d-dimer > 0.5ug/mL? Yes t ANY criteria Yes t EITHER criterin Discuss CXR findings and ptimal subsequent imaging mdality (e.g., CT angigram, ventilatin perfusin scintrigraphy) with Radilgy attending Is the Wells Criteria Scre > 4 pints OR is d-dimer > 0.5ug/mL? N t BOTH criteria Cnsider nn-urgent imaging fr PE, cnsider alternative diagnses Des imaging cnfirm PE? N Stp and cnsider alternative diagnses Yes Obtain STAT labs: Cmplete metablic panel, Brain natriuretic peptide, Cardiac trpnins Cntact Cardilgy cnsult team Hematlgy Fellw n-call (if n respnse within 20 minutes, cntact Hematlgy Attending) PICU Fellw n-call (and ntify Huse Supervisr) if PICU admissin is indicated CICU Fellw n-call if patient has underlying cardiac disease and CICU admissin is indicated Decide Antithrmbtic Therapy: Anticagulatin and/r Thrmblysis Start anticagulatin and/r thrmblysis with intravenus unfractinated heparin (ufh) until definitive antithrmbtic decisin is made. May start in ED, but d nt delay transfer t ICU. Patient hemdynamically unstable: Strngly cnsider thrmblysis fllwing review f cntraindicatins by Hematlgy, if cnsensus is achieved between ICU and Hematlgy attendings, and patient/parents give infrmed cnsent. Patient hemdynamically stable, but ech fulfills ANY criteria fr severe RV dysfunctin: Cnsider thrmblysis fllwing review f cntraindicatins by Hematlgy, if cnsensus is achieved between ICU and Hematlgy attendings, and patient/parents gives infrmed cnsent; if nt, anticagulate withut starting thrmblysis. Patient hemdynamically stable, but ech DOES NOT fulfill ANY criteria fr severe RV dysfunctin, anticagulate withut instituting thrmblysis. Evaluate Obtain imaging fr emblic surce (i.e., DVT) within 24 hurs Discuss ptimal imaging mdality with Radilgy attending (e.g., cmpressin ultrasund with Dppler, CT vengraphy, MR vengraphy) Page 1 f 14

2 TABLE OF CONTENTS Algrithm Target Ppulatin Backgrund Definitins Clinical Management Step 1. Start Step 2. Evaluate fr Urgent Imaging Step 3. Evaluate Imaging Step 4. Obtain Step 5. Cntact Step 6. Decide Antithrmbtic Therapies Step 7. Evaluate fr Surce Algrithm. Wells Scring Indicatins and Cntraindicatins fr Thrmblytic Therapy fr Acute VTE Cardilgy Checklist fr Right Ventricular (RV) Dysfunctin Evaluatin in Acute PE Further Management Setting: Flr/PICU Prir t Discharge Appendix 1. Additinal Diagnstic Cnsideratins fr PE Algrithm. Radilgy Diagnstic Imaging Schema fr Pssible PE in a Hemdynamically Stable Patient References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria: PE Risk Factrs Recent nset/wrsening f unexplained shrtness f breath r pleuritic chest pain (absence f knwn underlying cardiac disease, lung disease, r suspected acute pneumnia) Recent nset/wrsening f shrtness f breath r pleuritic chest pain, in the presence f knwn underlying cardiac disease, lung disease, r suspected acute pneumnia, but with ne f the fllwing PE risk factrs present: Painful leg swelling r knwn recent diagnsis f deep vein thrmbsis (DVT) Family r persnal histry f DVT r PE Knwn cltting disrder predispsing t DVT r PE Recent r current indwelling central venus catheter Elevated systemic estrgen (e.g., ral cntraceptive pill use, pregnancy) Recent immbility Recent majr r rthpedic surgery Acute r chrnic inflammatry cnditin Obesity Page 2 f 14

3 Exclusin Criteria N suspected PE BACKGROUND DEFINITIONS PE - Pulmnary Emblism DVT - Deep Vein Thrmbsis LMWH - Lw Mlecular Weight Heparin UFH - Unfractinated Heparin CLINICAL MANAGEMENT Gal: Cmplete steps 1 and 2 within ne hur f presentatin f suspected PE Step 1. Start Rm air pulse x Cnsider supplemental xygen IV access and STAT CBC and DIC screen Urine β-hcg, if apprpriate Chest x-ray (CXR) (PA + lateral), EKG and call the Cardilgy Fellw fr Ech review Step 2. Evaluate fr Urgent Imaging Des patient meet ne r mre f the fllwing criteria fr urgent imaging fr pssible PE? Painful leg swelling r knwn recent diagnsis f DVT Family r persnal histry f DVT r PE, especially befre age 55 yrs. Knwn cltting disrder predispsing t DVT r PE ( thrmbphilia ) Recent r current indwelling central venus catheter Elevated systemic estrgen (e.g., ral cntraceptive pill use, pregnancy) Recent immbility Recent majr r rthpedic surgery Recent majr r rthpedic trauma Acute r chrnic inflammatry cnditin (e.g., severe infectin, systemic lupus erythematsus r ther autimmunity) Obesity Cnsider Wells Criteria 8 fr patients 18 years and lder. Refer t Wells Scring algrithm 8. YES: (Step 2a.) Cnsider chest spiral CT angigram fr all patients as first line. If chest spiral CT angigram is cntraindicated discuss lung perfusin scintigraphy with radilgy attending t determine availability. Prceed t Step 3. Page 3 f 14

4 NO: (Step 2b.) Cnsider alternative diagnses, especially if d-dimer is negative. Cnsider nn-urgent imaging fr pssible PE. Step 3. Evaluate fr Imaging Des apprpriate imaging cnfirm the diagnsis f PE? YES: PE Cnfirmed (Step 3a.) Prceed t Step 4. NO: PE is nt cnfirmed (Step 3b.) If clinical suspicin fr PE is high, cnsider further imaging fr DVT. If nt, STOP and evaluate fr alternative diagnses. Step 4. Obtain STAT Labs: Cmplete metablic panel, brain natriuretic peptide (BNP), cardiac trpnins. Step 5. Cntact 1. Cntact Cardilgy Cnsult team t discuss indicatins (any ONE f the fllwing) fr urgent echcardigram: Hemdynamic instability RV strain n EKG Rm air xygen saturatin less than/equal t 92% and nt knwn t be patient s baseline Sudden change in xygen requirement PE invlves the main r prximal branch f a pulmnary artery (PA) PE invlves multiple lbar/segmental PA branches bilaterally *If nne f the abve is present, discuss the need fr nn-urgent Ech with Cardilgy. 2. Cntact Hematlgy Fellw n-call (if n respnse within 20 minutes, cntact Hematlgy Attending) Discuss initial antithrmbtic management using decisin tree belw. If urgent echcardigram is indicated r thrmblysis will therwise be cnsidered, then Hematlgy t evaluate patient at bedside within 1 hur f cnsultatin. If urgent echcardigram is indicated, start anticagulatin with intravenus ufh until definitive antithrmbtic decisin is made. 3. Cntact the apprpriate ICU (PICU r CICU) Fellw n-call (and ntify Huse Supervisr) if admissin is indicated. Step 6. Decide Antithrmbtic Therapy and/r Thrmblysis Start anticagulatin with intravenus unfractinated heparin (ufh) until definitive antithrmbtic decisin is made. May start in ED, but d nt delay transfer t the ICU. Patient is hemdynamically unstable: Strngly cnsider thrmblysis (Step 6b), fllwing review f indicatins and cntraindicatins fr thrmblytic therapy, if cnsensus achieved between ICU and Hematlgy attendings, and infrmed cnsent given by patient/parents. Page 4 f 14

5 Hemdynamic instability is defined as the requirement fr any pressr supprt in a patient withut underlying primary cardiac disease, r as the requirement fr any new/increase in pressr supprt in a patient with underlying primary cardiac disease. Patient is hemdynamically stable, but Ech fulfills ANY f the RV dysfunctin criteria: RV dysfunctin is defined as: Severe RV dilatin, (r) D-shaped LV (significant intraventricular septal flattening), (r) right ventricular hypertensin (TR velcity greater than >3 m/s r estimated RV pressure greater than 50% f systemic pressure). Cnsider thrmblysis fllwing review f indicatins and cntraindicatins fr thrmblytic therapy, if cnsensus achieved between ICU and Hematlgy attendings, and infrmed cnsent given by patient/parents (Appendix 1); If nt, anticagulate withut starting thrmblysis (Step 6b). If renal insufficiency r cncern fr increased bleeding risk (e.g., recent surgery, impending nn-elective surgery, clinical instability, disseminated intravascular cagulatin (DIC), liver disease), thrmblysis is nt recmmended. Prceed t Step 6a. Patient hemdynamically stable and Ech DOES NOT fulfill ANY criteria fr thrmblysis, anticagulate withut instituting thrmblysis (Step 6a). Step 6a. Anticagulant Treatment 1. Give unfractinated heparin IV blus and cntinuus IV infusin per CHCO frmulary. 2. Obtain anti-xa level, specify unfractinated heparin, by peripheral venipuncture 4 hurs after the initiatin f heparin infusin (8 hurs if blus is withheld because f clinical judgement). Anti-Xa gal is unit/ml Adjust per Anticagulatin Dsing and Mnitring Prtcls 3. Maintain platelet cunt greater than/equal t 50K/μL, with higher level required fr intubatin, insertin f central vascular access devices, and invasive prcedures (via platelet transfusin, if required) and fibringen greater than/equal t 100 g/dl (via FFP transfusin, if required). 4. Mnitr clinically fr signs/symptms f bleeding (premature nenates: add serial head U/S). Recheck anti-xa level when necessary fr bleeding cncerns. 5. CBC with platelet cunt every 24 t 48 hrs. in the absence f interim bleeding cncerns. Ntify Hematlgy fr decline in platelet cunt (cncern fr heparin-induced thrmbcytpenia). If recent bleeding r evidence f nging bleeding: Management as abve, with the exceptin that unfractinated heparin cntinuus infusin shuld be given with n blus, and platelet cunt shuld be maintained at 100K/μL. If n majr bleeding cncerns r unstable renal functin: 1. May give lw mlecular weight heparin (LMWH) as a subcutaneus injectin: fr current LMWH n-frmulary, view enxaparin in LexiCmp. 2. Anti-Xa gal range: units/ml 3. Adjust per CHCO s Anticagulatin Dsing and Mnitring Prtcls. Maintain platelet cunt greater than/equal t 50,000 (units?), with higher level required fr intubatin, insertin f central vascular access devices, and invasive prcedures (via platelet transfusin, if required) and fibringen greater than/equal t 100 g/dl (via FFP transfusin, if required). 4. Mnitr clinically fr signs/symptms f bleeding. Recheck 4 hurs pst-dse anti-xa LMWH assay prn bleeding cncerns r changes in renal functin. 5. Prceed t Step 7. Page 5 f 14

6 Step 6b. Thrmblytic Treatment (see cntraindicatins) Hematlgy bedside patient evaluatin within 2 hurs f cnsult request (if perfrmed by fellw, includes review with attending) If n cntraindicatins t systemic tpa: 1. Hematlgy t assist in discussin f risk and benefits f systemic thrmblysis with patient/family. 2. Dcument patient/family agreement with systemic thrmblysis. 3. Begin cntinuus IV infusin f systemic tpa at 0.03 mg/kg/hur t 0.1 mg/kg/hur (max: 2.5 mg/hr). Fr adults r teens weighing at least 50kg, may cnsider tpa 100mg IV infused ver 15 minutes t 2 hurs depending upn clinical severity. 4. Give cncmitant IV infusin f lw-dse unfractinated heparin at 10 units/kg/hr while receiving tpa, when tpa is cmplete patient shuld be immediately changed t therapeutic dses f heparin. 5. Check plasmingen level and CBC daily, and DIC screen every 6 hurs during systemic tpa infusin. Give FFP as needed t achieve plasmingen greater than/equal t lwer limit f nrmal values fr age (e.g., 70 units/dl r 70% in nn-nenatal children) and platelet transfusin as needed t maintain platelet cunt greater than/equal t 100K. 6. Mnitr clinically fr signs/symptms f bleeding. Stp tpa fr any majr bleeding cncerns (i.e., ther than bruising, transient epistaxis, r zing frm puncture sites, which are expected minr bleeding side-effects). Stp tpa fr any severe headache r any neurlgic changes (until intracranial hemrrhage is excluded by STAT CT f the head). 7. Repeat echcardigram daily fr up t fur days r stp sner if severe RV dysfunctin reslves. 8. When RV dysfunctin by echcardigraphy reslves OR after 96 hurs pst-initiatin f tpa infusin, cnsider discntinue tpa infusin and switch lw-dse unfractinated heparin infusin t therapeutic anticagulatin (see part 6a abve). If lnger infusin is being cnsidered this needs t be a deliberate decisin by all treating prviders and parents/patient. Step 7. Evaluate fr Surce Obtain imaging fr emblic surce (i.e. DVT) within 24 hurs Discuss ptimal imaging mdality with Radilgy attending (e.g., cmpressin ultrasund with Dppler, CT vengraphy, MR vengraphy) Patient with unilateral chest/arm swelling r central venus catheter at chest/arm: image ipsilateral arm Patient with unilateral leg swelling r central venus catheter at leg: image ipsilateral leg and pelvis Patient withut signs/symptms f DVT: image bilateral legs and pelvis. If evidence f prximal DVT, see als Acute Prximal DVT Clinical Pathway. Page 6 f 14

7 ALGORITHM. Wells Scring 8 Clinically Suspected PE Wells scre * Inclusin Criteria: Patients 18 years and lder with suspected pulmnary emblism Exclusin Criteria: Patients under age 18 4 pints (PE unlikely) > 4 pints (PE likely) D-dimer testing Negative result Pstive result Imaging fr PE PE ruled ut Negative result Pstive result * The Wells scre is a sum scre f the fllwing 7 variables: alternative diagnsis less likely than PE (3 pints), clinical signs and symptms f deep venus thrmbsis (3 pints), previus deep venus thrmbsis r PE (1.5 pints), tachycardia (1.5 pints), immbilizatin r surgery within the past 4 wk (1.5 pints), active cancer (treatment in the past 6 m, current treatment, r palliative care; 1 pint), and hemptysis (1 pint). Fixed D-dimer testing ( 500 μg/l) r age-adjusted D- dimer testing (age x 10 μg/l in patients aged >50 years), accrding t study prtcl. Page 7 f 14

8 INDICATIONS AND CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY FOR ACUTE VTE Indicatins (ONE f the fllwing criteria must be met) 1. Acute pulmnary emblism with evidence f severe right heart strain 2. Pulmnary emblism with hemdynamic instability 3. Prximal limb DVT with cncern fr acute limb ischemia refer t the prximal VTE clinical pathway 4. Cmpletely ven-cclusive limb DVT with factr VIII greater than/equal t 150 units/dl and D-dimer greater than/equal t 0.5 µg/ml *Fr all cntraindicatins the risk versus benefit f treatment must be weighed in patients with lifethreatening thrmbsis where alteplase may be the nly ptin. Cntraindicatins* (ABSOLUTE fr Systemic tpa) 1. Evidence f active hemrrhage 2. Prir histry f intracranial hemrrhage 3. Neursurgery, serius head trauma, r arterial ischemic strke during preceding 4 weeks 4. Gastrintestinal r urinary tract hemrrhage during preceding 3 weeks 5. Majr surgery (ther than neursurgery) r ther serius trauma (ther than head trauma) during preceding 2 weeks 6. Lumbar puncture r ther invasive prcedure during preceding 72 hurs 7. Uncntrlled hypertensin 8. Clinical presentatin suggesting endcarditis, pericarditis r large mycardial infarctin 9. Platelet cunt less than 100,000/mm at time f planned thrmblysis (if clinically apprpriate, may transfuse platelets t increase platelet cunt, in rder t avert cntraindicatin) 10. PTT (specimen drawn by clean peripheral venipuncture) prlnged by greater than t 4 secnds at time f planned thrmblysis that nrmalizes fllwing 1:1 mixing with pled plasma standard (N.B.: a prlnged PTT that desn t crrect n 1:1 mix is NOT a cntra-indicatin, as this likely represents a lupus anticagulant rather than a factr deficiency) 11. Fibringen less than 100 g/dl at time f planned thrmblysis (if clinically apprpriate, may cnsider cryprecipitate r FFP t increase fibringen, in rder t avert cntraindicatin) 12. Knwn AVM, aneurysm, CNS mass, r myamya 13. Status epilepticus 14. Histry f anaphylaxis t tpa Additinal RELATIVE Cntraindicatins* 15. Pregnant female 16. Recent unfractinated heparin use with anti-factr Xa activity (n a bld sample drawn by clean peripheral venipuncture) greater than/equal t 0.4 at time f planned thrmblysis (therapeutic unfractinated heparin shuld be reduced t prphylactic dsing (10 units/kg/hr) at least 2 hurs prir t initiatin f systemic tpa) 17. Recent lw mlecular weight heparin (LMWH) use with LMWH anti-factr Xa activity (n a bld sample drawn by clean peripheral venipuncture) greater than/equal t 0.6 at time f planned thrmblysis (therapeutic LMWH shuld be stpped r reduced t prphylactic dsing at least 12 hurs prir t initiatin f systemic tpa) 18. INR (specimen drawn by clean peripheral venipuncture) greater than/equal t 1.6 at time f planned thrmblysis (if clinically apprpriate, may cnsider FFP r lw-dse vitamin K administratin t reduce INR, in rder t avert cntraindicatin) 19. Arterial puncture at nn-cmpressible site during preceding 5 days 20. Lumbar puncture during preceding 5 days 21. Strke r serius head trauma during preceding 3 mnths 22. CPR with chest cmpressins within past 10 days 23. Recent dabigatran administratin within the preceding 24 hurs (cnsider the use f idaracizumab t reverse the anticagulant effect f dabigatran prir t tpa administratin) 24. Invasive prcedure (ther than majr surgery r lumbar puncture) within past 5 days 25. Knwn bleeding disrder/tendency (includes significant renal and hepatic insufficiency) 26. Aspirin r ther irreversible platelet inhibitr use within preceding 7 days 27. Life expectancy less than 6 mnths frm ther causes Page 8 f 14

9 CARDIOLOGY CHECKLIST FOR RIGHT VENTRICULAR (RV) DYSFUNCTION EVALUATION IN ACUTE PE (Patient meets any ONE f the fllwing criteria) Yes N 1. Severe RV dilatin Yes N 2. D-shaped LV (significant intraventricular septal flattening) Yes N 3. Right ventricular hypertensin (TR velcity greater than >3 m/s r estimated RV pressure greater than 50% f systemic RV pressure) FURTHER MANAGEMENT SETTING: FLOOR/ICU Cntinue anticagulant and/r thrmblytic treatment Cnsider institutin f peptic ulcer prphylaxis Fr systemic tpa: N central lines, Fley catheters, NG tube placement, arterial punctures, r ther similar invasive prcedures until at least 1 hur after cmpletin f tpa infusin. If any f thse are needed, stp tpa fr 1 hur and d nt restart unless there is clinical cnsensus that the benefits utweigh the risks. Fr systemic tpa: Cmpressin f arterial and venus puncture sites x 4 hurs after cmpletin f tpa infusin Hematlgy bedside patient evaluatin within 24 hurs f cnsult request (within 2 hurs f cnsult request if thrmblysis is being cnsidered) If recurrent PE (new, radilgically-dcumented event) ccurs n therapeutic anticagulatin r during systemic thrmblysis: cnsult IR fr temprary IVC filter placement If patient s cardirespiratry signs/symptms wrsen, btain urgent repeat spiral CT angigram f the chest If extensin f PE has ccurred n therapeutic anticagulatin, strngly cnsider systemic tpa If extensin f PE has ccurred n systemic tpa, strngly cnsider urgent UCH IR cnsultatin fr pssible interventinal thrmbectmy/thrmblysis, therapeutic r at minimum prphylactic levels f anticagulatin (typically with unfractinated heparin) shuld be maintained during interventinal thrmbectmy/thrmblysis. If patient is hemdynamically unstable and nt respnding t systemic tpa, strngly cnsider urgent UCH IR cnsultatin fr pssible interventinal thrmbectmy/thrmblysis. Therapeutic r at minimum prphylactic levels f anticagulatin (typically with unfractinated heparin) shuld be maintained during interventinal thrmbectmy/thrmblysis. PRIOR TO DISCHARGE Schedule fllw-up in Thrmbsis Clinic at 2-4 weeks pst-diagnsis Arrange Hematlgy versight f any anticagulatin (LMWH/warfarin) and its mnitring, as warranted Page 9 f 14

10 APPENDIX 1. ADDITIONAL DIAGNOSTIC CONSIDERATIONS FOR PE Indicatins fr radilgic imaging fr pssible PE rely upn clinical judgment; hwever, a few issues discussed belw are wrthy f cnsideratin. Wh shuld (and shuld nt) be imaged fr diagnsis f pssible PE? Data in adults suggests that patients in whm there is high clinical suspicin fr PE and in whm D-dimer is elevated are highly likely t have PE, while patients with lw clinical suspicin wh have a negative D-dimer have a lw likelihd fr PE. This has nt been systematically evaluated in children. Therefre, diagnstic radilgic evaluatin fr PE shuld be strngly cnsidered in any pediatric patient fr whm the diagnsis f PE is suspected clinically. What imaging mdality shuld be used t diagnse PE? There are n published studies dcumenting the sensitivity and specificity f diagnstic imaging tests fr pulmnary emblism in children. Prtcls are usually extraplated frm adult studies with little justificatin fr their applicability t children. The fllwing imaging mdalities have been used t evaluate children with clinical cncern fr PE: chest radigraph, chest CT angigraphy (CTA), pulmnary magnetic resnance angigraphy (MRA) and cnventinal pulmnary angigraphy. If indicated, may use ventilatin/perfusin scintigraphy in lieu f CTA (refer t Radilgy Diagnstic Imaging algrithm). Evaluatin shuld begin with chest radigraph (frntal and lateral views). Radigraphic findings in a patient with PE include airspace disease, atelectasis, pleural effusin, hypvascularity in a lung zne (Westermark sign) and a pyramid-shape pacity with peak directed t the hila (Hamptn hump). Unexpected findings (pneumthrax, mass) may alter the diagnstic algrithm away frm evaluatin fr PE. CTA shuld be cnsidered the preferred imaging mdality, given the lwer radiatin dse and increased yield regarding pulmnary parenchymal disease and ther differential diagnses. Perfusin Scintigraphy shuld be reserved fr thse with renal impairment r ther cntraindicatins t CT/MR. There are several prven advantages f CTA ver V/Q scan in adults: ability t visualize the thrmbus directly, identify ther diagnses if PE is nt present, mre cst-effective (with fewer indeterminate and nn-diagnstic results) and higher inter-bserver agreement. Central nn-bstructive embli can be clearly visible n CTA but may have nrmal pulmnary perfusin n scintigraphy. CTA has demnstrated high sensitivity and specificity in detectin f main, lbar and segmental pulmnary arteries but less with sub-segmental embli, althugh this may be imprved with use f dual energy CT technlgy which enables a map f the distributin f idine within the lung parenchyma, prviding functinal and quantitative infrmatin cmparable t scintigraphy. Pulmnary MRA is a nninvasive imaging technique in diagnsis f PE withut the need fr inizing radiatin r idinated cntrast media. Disadvantages include lng imaging time, need fr sedatin in yung children, and insensitivity t peripheral embli. MRA is currently cntraindicated in patients with pacemakers and sme ther implants. Sedatin shuld be undertaken with cautin in the setting f PE. MRA may be useful in children with suspected PE in whm idinated cntrast allergy pses a cntraindicatin t CTA, particularly when lung perfusin scintigraphy is nn-diagnstic. At present PIOPED III investigatrs suggest that pulmnary MRA shuld be cnsidered nly fr patients with cntraindicatins t standard tests and in centers that rutinely perfrm it, hwever many studies have been recently perfrmed shwing MRA t have a similar diagnstic efficacy t CT. Cnventinal pulmnary angigraphy is cnsidered the gld standard fr diagnsing PE but has largely been replaced by CTA. Its use is limited because f invasiveness, expense and ptential risk (arrhythmia, bleeding, infectin, death). The risk f pulmnary angigraphy in children suspected f PE is nt knwn. Page 10 f 14

11 ALGORITHM. Radilgy Diagnstic Imaging Schema fr Pssible PE in a Hemdynamically Stable Patient N Is a chest spiral CT angigram cntraindicated? Yes Inclusin Criteria: Patient has suspected pulmnary emblism Exclusin Criteria: N/A Chest spiral CT angigram Lung Perfusin Scintigraphy available? Yes N Lung Perfusin Scintigraphy Yes Lung Perfusin Scintigraphy results nrmal? N PE ruled ut If clinical crrelatin PE ruled in Page 11 f 14

12 REFERENCES 1. Mnagle P, Chan AKC, Gldenberg NA, Ichrd RN, Jurneycake JM, Nwak-GÖttl U, et al. Antithrmbtic therapy in nenates and children: antithrmbic therapy and preventin f thrmbsis, 9th ed.: American Cllege f Chest Phyisicans Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141: e737s-e801s. di /chest Kearn C, Kahn SR, Agnelli G, Gldhaber S, Raskb GE, Cmerta AJ. Antithrmbtic therapy fr venus thrmbemblic disease: American Cllege f Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Editin). Chest. 2008; 133(6 Suppl): 454S-545S. di: /chest Knstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus Alteplase Cmpared with Heparin Alne in Patients with Submassive Pulmnary Emblism. N Engl J Med. 2002; 347: di: /NEJMa Gldhaber SZ, Haire WD, Feldstein ML, et al. Alteplase versus heparin in acute pulmnary emblism: randmised trial assessing right-ventricular functin and pulmnary perfusin. Lancet. 1993; 341: Stein P, Wdard PK, Weg JG, Wakefield TW, Tapsn VF, Sstman HD, et al. Diagnstic pathways in acute pulmnary emblism: Recmmendatins f the PIOPED II Investigatrs. Radilgy. 2007; 242: di: /radil Manc-Jhnsn M. Hw I treat venus thrmbsis in children. Bld. 2006; 107(1): di: /bld Gldenberg NA, Bernard TJ. Arterial ischemic strke in nenates and children. Pediatr Clin Nrth Am. 2008; 55: Van Es, N, van der Hulle T, van Es J, den Exter PL, Duma RA, Gekp RJ, et al. Wells Rule and d-dimer testing t rule ut pulmnary emblism: a systematic review and individual-patient data meta-analysis. Ann Intern Med. 2016; 165(4): di: /M Zhang LJ, Lu S, Yeh BM, Zhu CS, Tang CX, Zha Y, Li L, Zheng L, Huang W, Lu GM. Diagnstic accuracy f three-dimensinal cntrast-enhanced MR angigraphy at 3-T fr acute pulmnary emblism detectin: cmparisn with multidetectr CTangigraphy. Int J Cardil Oct 12;168(5): Page 12 f 14

13 CLINICAL IMPROVEMENT TEAM MEMBERS Michael Wang, MD Hematlgy Timthy Schardt, PharmD Pharmacy Peter Murani, MD Intensive Care Shelley Miyamt, MD Cardilgy Jhn Kim, MD Cardilgy Nidhya Navanandan, MD Emergency Medicine Kathryn Rappaprt, MD Emergency Medicine Lrna Brwne, MD Radilgy Angela Swansn, MS Clinical Effectiveness Sarah Nickels, PhD Clinical Effectiveness APPROVED BY Pharmacy & Therapeutics Cmmittee March 9, 2017 Clinical Pathways and Measures Cmmittee August 21, 2017 MANUAL/DEPARTMENT Clinical Care Guidelines/Quality ORIGINATION DATE January 1, 2009 LAST DATE OF REVIEW OR REVISION August 21, 2017 APPROVED BY REVIEW REVISION SCHEDULE Scheduled fr full review n August 21, Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 13 f 14

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