eMedicine Specialties > Pulmonology > Pulmonary Embolism
Pulmonary Embolism: Multimedia
Updated: Aug 25, 2009
Multimedia
 | Media file 1: A large pulmonary artery thrombus in a hospitalized patient who died suddenly. |
 | Media file 2: Pulmonary embolism was identified as the cause of death in a patient who developed shortness of breath while hospitalized for hip joint surgery. This is a close-up view. |
 | Media file 3: Lung infarction secondary to pulmonary embolism occurs rarely. |
 | Media file 4: Posteroanterior and lateral chest radiograph findings are normal, which is the usual finding in patients with pulmonary embolism. |
 | Media file 5: High-probability perfusion lung scan shows segmental perfusion defects in the right upper lobe and subsegmental perfusion defects in right lower lobe, left upper lobe, and left lower lobe. |
 | Media file 6: A normal ventilation scan will make the above-noted defects in Image 5 a mismatch and, hence, a high-probability ventilation-perfusion scan. |
 | Media file 7: Anterior views of perfusion and ventilation scans are shown here. A perfusion defect is present in the left lower lobe, but perfusion to this lobe is intact, making this a high-probability scan. |
 | Media file 8: A segmental ventilation perfusion mismatch evident in a left anterior oblique projection. |
 | Media file 9: A pulmonary angiogram shows the abrupt termination of the ascending branch of the right upper-lobe artery, confirming the diagnosis of pulmonary embolism. |
 | Media file 10: A chest radiograph with normal findings in a 64-year-old woman who presented with worsening breathlessness. |
 | Media file 11: This perfusion scan shows bilateral perfusion defects. The ventilation scan findings were normal; therefore, these are mismatches, and this is a high-probability scan. |
 | Media file 12: A spiral CT scan shows thrombus in bilateral main pulmonary arteries. |
 | Media file 13: A spiral CT scan shows thrombus in bilateral main pulmonary arteries. |
 | Media file 14: Ultrasound shows the thrombus in the distal superficial saphenous vein, which is under the artery. |
 | Media file 15: A lack of respiratory variation in the Doppler waveform of the popliteal vein. |
 | Media file 16: This ultrasound shows the thrombus tip in the superficial femoral vein, with a small amount of flow around it. The color flow deep into the superficial femoral vein is from the profunda femoris vein. |
 | Media file 17: An ultrasound shows the thrombus filling the superficial femoral vein; the noncompressibility further confirms the diagnosis. |
 | Media file 18: A posteroanterior chest radiograph showing a peripheral wedge-shaped infiltrate caused by pulmonary infarction secondary to pulmonary embolism. Hampton hump is a rare and nonspecific finding. Courtesy of Justin Wong, MD. |
 | Media file 19: CT scan of the same chest depicted in Image 18. Courtesy of Justin Wong, MD. |
More on Pulmonary Embolism |
| Overview: Pulmonary Embolism |
| Differential Diagnoses & Workup: Pulmonary Embolism |
| Treatment & Medication: Pulmonary Embolism |
| Follow-up: Pulmonary Embolism |
 Multimedia: Pulmonary Embolism |
| References |
| « Previous Page |
References
Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med. Jul 28 2003;163(14):1711-7. [Medline]. [Full Text].
Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol. Apr 2008;63(4):381-6. [Medline].
DeMonaco NA, Dang Q, Kapoor WN, Ragni MV. Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med. Jul 2008;121(7):611-7. [Medline].
Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. Nov 15 2005;143(10):697-706. [Medline].
Kuklina EV, Meikle SF, Jamieson DJ, et al. Severe obstetric morbidity in the United States: 1998-2005. Obstet Gynecol. Feb 2009;113(2 Pt 1):293-9. [Medline].
Schneider D, Lilienfeld DE, Im W. The epidemiology of pulmonary embolism: racial contrasts in incidence and in-hospital case fatality. J Natl Med Assoc. Dec 2006;98(12):1967-72. [Medline]. [Full Text].
Worsley DF, Alavi A. Comprehensive analysis of the results of the PIOPED Study. Prospective Investigation of Pulmonary Embolism Diagnosis Study. J Nucl Med. Dec 1995;36(12):2380-7. [Medline]. [Full Text].
Amesquita M, Cocchi MN, Donnino MW. Pulmonary Embolism Presenting as Flank Pain: A Case Series. J Emerg Med. Mar 26 2009;[Medline].
Carrascosa MF, Batan AM, Novo MF. Delirium and pulmonary embolism in the elderly. Mayo Clin Proc. 2009;84(1):91-2. [Medline]. [Full Text].
Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. Dec 15 1994;331(24):1601-6. [Medline].
Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. Oct 2007;120(10):871-9. [Medline]. [Full Text].
Restrepo CS, Artunduaga M, Carrillo JA, et al. Silicone pulmonary embolism: report of 10 cases and review of the literature. J Comput Assist Tomogr. Mar-Apr 2009;33(2):233-7. [Medline].
Tapson VF. Acute pulmonary embolism. N Engl J Med. Mar 6 2008;358(10):1037-52. [Medline].
[Guideline] Qaseem A, Snow V, Barry P, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. Jan-Feb 2007;5(1):57-62. [Medline].
[Guideline] Qaseem A, Snow V, Barry P, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. Mar 20 2007;146(6):454-8. [Medline].
[Best Evidence] Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. Feb 7 2006;144(3):165-71. [Medline]. [Full Text].
Klok FA, Kruisman E, Spaan J, et al. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost. Jan 2008;6(1):40-4. [Medline].
Douma RA, Gibson NS, Gerdes VE, et al. Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost. Jan 2009;101(1):197-200. [Medline].
[Best Evidence] Klok FA, Mos IC, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. Oct 27 2008;168(19):2131-6. [Medline].
Kearon C, Ginsberg JS, Douketis J, et al. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med. Jun 6 2006;144(11):812-21. [Medline]. [Full Text].
Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. Apr 20 2004;140(8):589-602. [Medline]. [Full Text].
Konstantinides S. Clinical practice. Acute pulmonary embolism. N Engl J Med. Dec 25 2008;359(26):2804-13. [Medline].
Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol. Nov 1 2000;36(5):1632-6. [Medline].
Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. Jul 24 2007;116(4):427-33. [Medline].
Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Buller HR. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. Mar 2006;4(3):552-6. [Medline].
Cavallazzi R, Nair A, Vasu T, Marik PE. Natriuretic peptides in acute pulmonary embolism: a systematic review. Intensive Care Med. Dec 2008;34(12):2147-56. [Medline].
Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation. May 27 2003;107(20):2545-7. [Medline].
[Guideline] Bettmann MA, Lyders EM, Yucel EK, et al. ACR Appropriateness Criteria acute chest pain—suspected pulmonary embolism. American College of Radiology. National Guideline Clearinghouse. 2006;April 13, 2009. [Full Text].
van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. Jan 11 2006;295(2):172-9. [Medline]. [Full Text].
Moores LK, Jackson WL Jr, Shorr AF, Jackson JL. Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern Med. Dec 7 2004;141(11):866-74. [Medline]. [Full Text].
Gottschalk A, Stein PD, Sostman HD, Matta F, Beemath A. Very low probability interpretation of V/Q lung scans in combination with low probability objective clinical assessment reliably excludes pulmonary embolism: data from PIOPED II. J Nucl Med. Sep 2007;48(9):1411-5. [Medline]. [Full Text].
[Best Evidence] Vanni S, Polidori G, Vergara R, et al. Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure. Am J Med. Mar 2009;122(3):257-64. [Medline].
[Guideline] Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):454S-545S. [Medline].
Garcia D, Ageno W, Libby E. Update on the diagnosis and management of pulmonary embolism. Br J Haematol. Nov 2005;131(3):301-12. [Medline].
Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ. Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial. BMJ. Mar 31 2007;334(7595):674. [Medline].
Pinede L, Ninet J, Duhaut P, et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation. May 22 2001;103(20):2453-60. [Medline].
Ballew KA, Philbrick JT, Becker DM. Vena cava filter devices. Clin Chest Med. Jun 1995;16(2):295-305. [Medline].
Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. Feb 12 1998;338(7):409-15. [Medline].
Cavallazzi R, Nair A, Vasu T, Marik PE. Natriuretic peptides in acute pulmonary embolism: a systematic review. Intensive Care Med. Dec 2008;34(12):2147-56. [Medline].
Alonso-Martinez JL, Urbieta-Echezarreta M, Anniccherico-Sanchez FJ, Abinzano-Guillen ML, Garcia-Sanchotena JL. N-terminal pro-B-type natriuretic peptide predicts the burden of pulmonary embolism. Am J Med Sci. Feb 2009;337(2):88-92. [Medline].
Adam SS, Key NS, Greenberg CS. D-dimer antigen: current concepts and future prospects. Blood. Mar 26 2009;113(13):2878-87. [Medline].
Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L, Dalen JE. Mortality in patients treated for pulmonary embolism. JAMA. Sep 27 1976;236(13):1477-80. [Medline].
Brill-Edwards P, Ginsberg JS, Johnston M, Hirsh J. Establishing a therapeutic range for heparin therapy. Ann Intern Med. Jul 15 1993;119(2):104-9. [Medline].
Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol. Jun 2004;7(2):50-4. [Medline].
Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary embolism. N Engl J Med. May 7 1992;326(19):1240-5. [Medline].
Davey NC, Smith TP, Hanson MW, Lee VS, Stackhouse DJ, Coleman RE. Ventilation-perfusion lung scintigraphy as a guide for pulmonary angiography in the localization of pulmonary emboli. Radiology. Oct 1999;213(1):51-7. [Medline].
Deitelzweig S, Jaff MR. Medical management of venous thromboembolic disease. Tech Vasc Interv Radiol. Jun 2004;7(2):63-7. [Medline].
Drucker EA, Rivitz SM, Shepard JA, et al. Acute pulmonary embolism: assessment of helical CT for diagnosis. Radiology. Oct 1998;209(1):235-41. [Medline].
Egermayer P, Town GI, Turner JG, Heaton DC, Mee AL, Beard ME. Usefulness of D-dimer, blood gas, and respiratory rate measurements for excluding pulmonary embolism. Thorax. Oct 1998;53(10):830-4. [Medline].
Ginsberg JS. Management of venous thromboembolism. N Engl J Med. Dec 12 1996;335(24):1816-28. [Medline].
Ginsberg JS, Hirsh J. Use of antithrombotic agents during pregnancy. Chest. Nov 1998;114(5 Suppl):524S-530S. [Medline].
Ginsberg JS, Wells PS, Kearon C, et al. Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. Ann Intern Med. Dec 15 1998;129(12):1006-11. [Medline].
Gottschalk A, Stein PD, Goodman LR, Sostman HD. Overview of Prospective Investigation of Pulmonary Embolism Diagnosis II. Semin Nucl Med. Jul 2002;32(3):173-82. [Medline]. [Full Text].
Hirsh J, Dalen JE, Anderson DR, et al. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest. Nov 1998;114(5 Suppl):445S-469S. [Medline].
Howarth DM, Booker JA, Voutnis DD. Diagnosis of pulmonary embolus using ventilation/perfusion lung scintigraphy: more than 0.5 segment of ventilation/perfusion mismatch is sufficient. Intern Med J. May 2006;36(5):281-8. [Medline].
Hull R, Delmore T, Carter C, et al. Adjusted subcutaneous heparin versus warfarin sodium in the long-term treatment of venous thrombosis. N Engl J Med. Jan 28 1982;306(4):189-94. [Medline].
Hull R, Delmore T, Genton E, et al. Warfarin sodium versus low-dose heparin in the long-term treatment of venous thrombosis. N Engl J Med. Oct 18 1979;301(16):855-8. [Medline].
Hull RD, Raskob GE, Brant RF, Pineo GF, Valentine KA. The importance of initial heparin treatment on long-term clinical outcomes of antithrombotic therapy. The emerging theme of delayed recurrence. Arch Intern Med. Nov 10 1997;157(20):2317-21. [Medline].
Hull RD, Raskob GE, Ginsberg JS, et al. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism. Arch Intern Med. Feb 14 1994;154(3):289-97. [Medline].
Hull RD, Raskob GE, Rosenbloom D, et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med. Aug 1992;152(8):1589-95. [Medline].
Katz DS, Hon M. Current DVT imaging. Tech Vasc Interv Radiol. Jun 2004;7(2):55-62. [Medline].
Kluetz PG, White CS. Acute pulmonary embolism: imaging in the emergency department. Radiol Clin North Am. Mar 2006;44(2):259-71, ix. [Medline].
Kovacs MJ, Anderson D, Morrow B, Gray L, Touchie D, Wells PS. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost. Feb 2000;83(2):209-11. [Medline].
Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. Mar 14 1996;334(11):677-81. [Medline].
Levine M, Hirsh J, Weitz J, et al. A randomized trial of a single bolus dosage regimen of recombinant tissue plasminogen activator in patients with acute pulmonary embolism. Chest. Dec 1990;98(6):1473-9. [Medline].
Marks PW. Management of thromboembolism in pregnancy. Semin Perinatol. Aug 2007;31(4):227-31. [Medline].
Matthews S. Short communication: imaging pulmonary embolism in pregnancy: what is the most appropriate imaging protocol?. Br J Radiol. May 2006;79(941):441-4. [Medline].
Mayo JR, Remy-Jardin M, Muller NL, et al. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Radiology. Nov 1997;205(2):447-52. [Medline].
Moser KM. Venous thromboembolism. Am Rev Respir Dis. Jan 1990;141(1):235-49. [Medline].
Mullins MD, Becker DM, Hagspiel KD, Philbrick JT. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med. Feb 14 2000;160(3):293-8. [Medline].
O'Neill JM, Wright L, Murchison JT. Helical CTPA in the investigation of pulmonary embolism: a 6-year review. Clin Radiol. Sep 2004;59(9):819-25. [Medline].
Ramzi DW, Leeper KV. DVT and pulmonary embolism: Part I. Diagnosis. Am Fam Physician. Jun 15 2004;69(12):2829-36. [Medline].
Ramzi DW, Leeper KV. DVT and pulmonary embolism: Part II. Treatment and prevention. Am Fam Physician. Jun 15 2004;69(12):2841-8. [Medline].
Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med. Feb 1 2000;132(3):227-32. [Medline].
Rosendaal FR. Venous thrombosis: prevalence and interaction of risk factors. Haemostasis. Dec 1999;29 Suppl S1:1-9. [Medline].
Schaefer-Prokop C, Prokop M. MDCT for the diagnosis of acute pulmonary embolism. Eur Radiol. Nov 2005;15 Suppl 4:D37-41. [Medline].
Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med. Feb 6 1997;336(6):393-8. [Medline].
Simonneau G, Sors H, Charbonnier B, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire. N Engl J Med. Sep 4 1997;337(10):663-9. [Medline].
Stein PD, Hull RD, Saltzman HA, Pineo G. Strategy for diagnosis of patients with suspected acute pulmonary embolism. Chest. May 1993;103(5):1553-9. [Medline].
Stein PD, Saltzman HA, Weg JG. Clinical characteristics of patients with acute pulmonary embolism. Am J Cardiol. Dec 15 1991;68(17):1723-4. [Medline].
Tapson VF. Pulmonary embolism: the diagnostic repertoire. Chest. Sep 1997;112(3):578-80. [Medline].
Tibbutt DA, Davies JA, Anderson JA, et al. Comparison by controlled clinical trial of streptokinase and heparin in treatment of life-threatening pulmonay embolism. Br Med J. Mar 2 1974;1(5904):343-7. [Medline].
Warkentin TE. Think of HIT. Hematology. 2006;1:408-414.
Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):340S-380S. [Medline].
Wells PS. Advances in the diagnosis of venous thromboembolism. J Thromb Thrombolysis. Feb 2006;21(1):31-40. [Medline].
Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. Dec 15 1998;129(12):997-1005. [Medline].
Further Reading
Keywords
pulmonary embolism, pulmonary emboli, venous thromboembolism, PE, obstructive shock, deep vein thrombosis, deep venous thrombosis, DVT, hemodynamic collapse, acute pulmonary infarction, pulmonary hypertension, cor pulmonale
pleuritic chest pain, hemoptysis, venous stasis, polycythemia, immobility, hypercoagulability, factor V Leiden mutation, pancreatic carcinoma, bronchogenic carcinoma, carcinoma of the genitourinary tract, colon cancer, breast cancer, congestive heart failure, stroke, obesity, varicose veins, inflammatory bowel disease
