Mercy Hospital
DEM Pulmonary Embolism Evaluation Guidelines
(with new ELISA D-Dimer)

Draft 6/15/00

         Assess Clinical Probability for PE
        /                                  \
   Low                    Intermediate or High Probability
 Pretest                                   |
Suspicion                                  v
  <20%                             D-Dimer AND V/Q scan
    |               --------->------------>|
    v              |                       v
  D-Dimer          | =Normal VQ, negative D-Dimer: discharge
=negative:         | =Low-Prob VQ, negative D-Dimer: discharge
 send home         ^ =Low-Prob VQ, + D-Dimer-------
 99.1% negative    | =Intermediate VQ, + D-Dimer---|
 predictive valude | =Intermediate VQ, - D-Dimer---|
=positive-------->-  =High-Prob VQ: treat for PE   v
                       irrespective of D-Dimer      |
                                       -----<-------
                                      |
                                      v
                           Lower Extremity Doppler
                           Venous Ultrasound Study
                                      |
                                      v
  =Low-Prob VQ,     + D-Dimer, - Doppler: Discharge
  =Intermediate VQ, + D-Dimer, + Doppler: Treat for DVT
  =Intermediate VQ, + D-Dimer, - Doppler: Angio or Spiral CT
  =Intermediate VQ, - D-Dimer, + Doppler: Treat for DVT
  =Intermediate VQ, - D-dimer, - Doppler: Discharge