Clinical Decision Support Tools

Decision Support Algorithm for Patients with Suspected PE

Eligible

Does the patient have suspected PE?

Y

N

Does the patient have any of the following exclusions?

Unstable patient

Patient currently has known DVT/PE

Anticoagulated

Pregnant

The patient has none of the above exclusions

The use of age-adjusted d-dimer cutoffs (age × 0.01 mg/L) for patients above age 50 has been shown to significantly improve specificity of the d-dimer assay (reducing false positives) without increasing the number of missed cases (Schouten BMJ 2013).

Examples:

Age adjusted cutoff for patient age 51:
51 x 0.01mg/L = 0.51 mg/L FEU

Age adjusted cutoff for patient age 86:
86 x 0.01mg/L = 0.86 mg/L FEU.”

Thank you for using the PE tool.
Please order a d-dimer.
You may keep this window open to save the data you have already entered.
Please enter the d-dimer result when obtained.

D-dimer Result:

Positive

Negative

Thank you for using the PE tool.
Please order your preferred imaging test.
You may keep this window open to save the data you have already entered.
Please enter the result when obtained.

Imaging Method:

Treatment decision made

Stop investigations

Override decision support

Print Patient Handout More Information

Thank you for using the PE tool. You may click on "Print for Chart" for a physical copy of the decision support recommendation and you can close the window

Probability of Neurosurgical Intervention

DIAGNOSTIC TEST PERFORMANCE

The quoted probabilities of DVT/PE events in the distal branches of the diagnostic management tree shown above are for the likelihood of new DVT or PE events in the next 3 months.
Published evidence on diagnostic test performance (i.e., sensitivities, specificities, and/or likelihood ratios) can be used to calculate post-test probabilities of PE, that estimate the probability of PE for your patient right now, given the pre-test probability and the imaging test result.

BAYESIAN CALCULATED ESTIMATE

The probability quoted in the following Nomogram is a calculated estimate of your patient’s probability of having a PE right now, based on the best available evidence on diagnostic test performance.
This is distinct, and in some instances different, from the previously quoted probabilities of developing a new PE or DVT in 3 months of follow-up.
Many small and/or peripheral PE’s missed by imaging studies are of limited clinical significance. It is for this reason that management recommendations in diagnostic management tree shown above are most heavily informed by the well-studied probabilities of new events in 3 months of follow-up.

FAGAN NOMOGRAM

Decision Support Algorithm for Patients with Suspected PE

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Positive

Negative

Positive

Negative

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Probability of Neurosurgical Intervention

More Information

PERC Rule Meta-Analysis

D-dimer for Ruling Out PE Meta-Analysis

Age-Adjusted D-dimer for Ruling out PE Meta-Analysis

CTPA for Ruling out Pulmonary Embolism Meta-Analysis