**12.2.3 Diagnosis**

56 Pulmonary Embolism

malignancy, and infections that are all frequent in the elderly and may on occasion be

The most common and serious major error is one of omissions, when the diagnosis simply is not considered clinically and is confirmed only at autopsy. Pleural changes and possibly some local asymmetric changes in vascularity may be detected if the film is keenly studied; however, the most common finding is that of an essentially normal chest roentgenogram in

Bed rest and inactivity pose the greatest risk for developing of deep vein thrombosis. Certain medical conditions common among the elderly (eg, trauma to leg vessels, obesity (Barba et al., 2008), heart failure, malignancy, hip fracture, myeloproliferative disorders) predispose them to venous thrombosis, as do smoking, estrogen usage (LaCroix et al., 2011; Sare et al., 2008), tamoxifen therapy, the presence of a femoral venous catheter, and surgery (Barba et al., 2008). Risk factors for venous thrombosis are vessel wall injury, stasis, and conditions that increase the tendency of the blood to clot, including rare deficiencies of antithrombin III, protein C, and protein S as well as disseminated intravascular coagulation, polycythemia vera, or the presence of a lupus anticoagulant or antiphospholipid antibodies. Ageing is also associated with increased coagulation and products of fibrinolysis, resulting

About 90% of blood clots that cause pulmonary embolism originate in the legs. The risk that a clot will embolize and lodge in the lungs is greater if the clot is in the popliteal or iliofemoral vein (about 50%) than if it is confined to the calf veins (< 5%). Less common sites of thrombosis that may lead to pulmonary embolism are the right atrium, the right ventricle,

In elderly patients, the most common symptoms are tachypnea (respiratory rate > 16 breaths/minute), shortness of breath, chest pain that may be pleuritic, anxiety, leg pain or swelling, hemoptysis, and syncope. Patients who have small thromboemboli may be asymptomatic or have atypical symptoms. Nonspecific symptoms suggestive of pulmonary emboli in the elderly include persistent low-grade fever, change in mental status, or a

Patients with pulmonary embolism (West, 2007) usually present with one of the following symptom patterns: (1) diagnostically confusing syndromes (confusion, unexplained fever, wheezing, resistant heart failure, unexplained arrhythmias); (2) transient shortness of breath and tachypnea; (3) pulmonary infarction (pleuritic pain, cough, hemoptysis, pleural effusion, pulmonary infiltrate); (4) right-sided heart failure along with shortness of breath and tachypnea secondary to pulmonary embolism; or (5) cardiovascular collapse with hypotension and syncope. Fewer than 20% of elderly patients have the classic triad of dyspnea, chest pain, and hemoptysis. If tachypnea is absent, pulmonary embolism is

The most common physical findings are tachypnea, tachycardia, fever, leg edema or tenderness, cyanosis, and a pleural friction rub. Although most elderly patients with pulmonary embolism have deep vein thrombosis as the initial source of the embolus, only

confused with pulmonary embolism.

in an overall prethrombotic state.

**12.2.2 Symptoms and signs** 

unlikely to occur.

clinical picture that mimics airway infection.

33% have clinical signs of leg thrombosis.

and the pelvic, renal, hepatic, subclavian, and jugular veins.

a very sick patient.

**12.2.1 Etiology** 

The most important consideration for determining the extent of testing is the clinical assessment of pretest probability (Bertoletti et al., 2011). The clinical probability (Wells or Geneva score) of pulmonary embolism pretest places patients into low-, moderate- , or high-probability groups. This grouping is combined with the results of ventilationperfusion scans or of spiral chest CT scans to determine whether further testing is needed.

Very useful and easy for diagnosis of PE in daily clinical practice in elderly patients seems to be the combination of clinical pretest probability (PTP) and D-dimer result (Pasha et al., 2010). In VIDAS study the combination of a negative D-dimer result and non-high PTP effectively and safely excludes PE in an important proportion of outpatients with suspected PE (Carrier et al., 2009).
