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Pulmonary embolism (PE) is a condition in which one or more emboli,…

- - - - Non-thrombotic sources of emboli include [Camm and Bunce, 2005] [Konstantinides, 2014]:
      - Tumours — most commonly prostate and breast cancers.
      - Fat — from long-bone fractures.
      - Amniotic fluid in pregnant women.
      - Sepsis — for example, tricuspid valve endocarditis in people who inject illicit drugs intravenously or have infected indwelling catheters or pacemaker wires; people with peripheral septic thrombophlebitis; or recipients of transplanted organs.
      - Foreign bodies — during intravenous drug use or from broken catheters, guide wires, vena cava filters, embolization coils, and endovascular stent components.
      - Air — admitted during surgery or from other communication between the environment and the venous system.
  - - - Major risk factors for pulmonary embolism (PE) include:
      - Deep vein thrombosis (DVT) — about 70–80% of people with symptomatic PE have concomitant DVT, which is symptomatic in up to 25% of cases [Konstantinides, 2014; Di Nisio, 2016]. Conversely, asymptomatic PE is present in at least 30% of people with symptomatic DVT [Konstantinides, 2014; Di Nisio, 2016].
      - Previous VTE — about 30% of people with PE (or DVT) have a recurrence within 10 years [Di Nisio, 2016]. Recurrence is more frequent after multiple episodes of VTE [Konstantinides, 2014].
      - Active cancer — accounts for about 20% of cases of VTE [Di Nisio, 2016; Heit, 2016; Konstantinides, 2016; BMJ, 2018]. The risk of VTE in people with cancer is fourfold higher than in the general population [Konstantinides, 2016], and varies with different types of cancer; haematological, lung, gastrointestinal pancreatic, and brain cancers carry the highest risk. In addition, cancer is a strong risk factor for all-cause mortality following an episode of VTE [Konstantinides, 2014]. There is a threefold increased risk of recurrent VTE with cancer [National Clinical Guideline Centre, 2012].
      - Recent surgery — surgery within the last 2 months accounts for about 29% of cases of confirmed PE [BMJ, 2018]. The risk of VTE is especially high for people undergoing major orthopaedic surgery, with postoperative rates of around 1% despite anticoagulation treatment [Di Nisio, 2016].
      - Significant immobility, for example, due to hospitalization or bed rest — compared with residents in the community, hospitalized residents have over a 100-fold increased incidence of VTE, and nursing home residence independently accounts for over 10% of all cases of VTE [Heit, 2016]. Bed rest (longer than 5 days) accounts for 28% of cases of confirmed PE [BMJ, 2018].
      - Lower limb trauma or fracture — accounts for about 11% of cases of confirmed PE [BMJ, 2018].
      - Pregnancy and, in particular, for 6 weeks' postpartum — the risk of antenatal VTE is four to five-fold higher in pregnant women than in nonpregnant women of the same age (although the absolute risk remains low at around 1 in 1000 pregnancies). The puerperium is the time of highest risk, with estimates of relative risk of approximately 20-fold [RCOG, 2015].
      - Other risk factors include:
      - Increasing age (older than 60 years of age).
      - The use of combined oral contraception or hormone replacement therapy (within the last 6 weeks to 3 months before diagnosis).
      - Obesity (body mass index greater than 30 kg/m2).
      - One or more significant medical comorbidities, for example, heart disease; metabolic, endocrine, neurological disability, or respiratory pathologies; acute infectious disease; or inflammatory conditions.
      - Long-distance sedentary travel.
      - Varicose veins.
      - Superficial venous thrombosis.
      - Known thrombophilias (thrombotic disorders).
      - Other factors, such as indwelling central vein catheter, nephrotic syndrome, chronic dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, or Behçet's disease.
    - - uritic chest pain, and/or features of deep vein thrombosis (DVT), including leg pain and swelling (usually unilateral), lower abdominal pain, redness, increased temperature, and venous distension.
        
        Other symptoms that may be present include:
        
        Retrosternal chest pain (due to right ventricular ischaemia).
        
        Cough and haemoptysis.
        
        In severe cases, dizziness and/or syncope (due to right ventricular failure).
        
        Other signs that may be present include:
        
        Tachycardia (heart rate greater than 100 beats per minute).
        
        Hypoxia.
        
        Pyrexia.
        
        Elevated jugular venous pressure.
        
        Gallop rhythm, a widely split second heart sound, tricuspid regurgitant murmur.
        
        Pleural rub.
        
        Hypotension (systolic blood pressure less than 90 mmHg) and cardiogenic shock (rare signs indicating central PE and/or a severely reduced haemodynamic reserve).
        
        The presence of risk factors, such as pregnancy, previous DVT or PE, active cancer, or recent surgery, makes the diagnosis of PE more likely.
        
        Be aware that PE may be completely asymptomatic and be discovered incidentally when assessing for another condition.
        
        If PE is suspected:
        
        Carry out an assessment of their general medical history, a physical examination, and, where necessary, investigations (such as a chest X-ray or electrocardiogram [ECG]) to:
        
        Exclude other causes of symptoms, including other respiratory conditions (such as pneumothorax and pneumonia) and cardiac causes (such as acute coronary syndrome and acute congestive heart failure).
        
        Assess for risk factors (such as pregnancy and immobilization).
        
        Do not delay management for results of a chest X-ray or ECG.
        
        Abnormalities on chest X-ray or ECG are not specific for PE, but might be useful in the differential diagnosis.
        
        Chest X-ray features that may be present include atelectasis, pleural effusion, or elevation of a hemidiaphragm.
        
        ECG signs that may be present include sinus tachycardia, non-specific ST-segment and T-wave abnormalities, right axis deviation, incomplete or complete right bundle-branch block, and, less commonly, T-wave inversion in leads V1–V3, P pulmonale, or the classical S1, Q3, T3 (S wave in lead 1, Q wave in lead 3, and T-wave inversion in lead 3).
  - - - Conditions that can cause similar symptoms to pulmonary embolism (PE) include:
      - Other respiratory conditions, such as:
      - Pneumothorax.
      - Pneumonia.
      - Acute bronchitis.
      - Acute exacerbation of asthma. For more information, see the CKS topic on Asthma.
      - Acute exacerbation of chronic obstructive pulmonary disease (COPD). For more information, see the CKS topic on Chronic obstructive pulmonary disease.
      - Acute exacerbation of chronic lung disease.
      - Cardiac causes, such as:
      - Acute coronary syndrome.
      - Acute congestive heart failure.
      - Dissecting or rupturing aortic aneurysm.
      - Unstable angina. For more information, see the CKS topic on Angina.
      - Myocardial infarction. For more information, see the CKS topic on MI - secondary prevention.
      - Pericarditis.
      - Musculoskeletal chest pain. Note that chest pain with chest wall palpation occurs in up to 20% of people with confirmed PE.
      - Gastro-oesophageal reflux disease. For more information, see the CKS topic on Dyspepsia - proven GORD.
      - Any cause for collapse, such as:
      - Vasovagal syncope.
      - Orthostatic (postural) hypotension.
      - Cardiac arrhythmias. For more information, see the CKS topic on Atrial fibrillation.
      - Seizures. For more information, see the CKS topic on Epilepsy.
      - Cerebrovascular disorders. For more information, see the CKS topic on Stroke and TIA.