Prise en charge de l'embolie pulmonaire en urgence

Pulmonary embolism is a leading cause of death in the general population. The diagnosis must be suspected in patients with unusual dyspnea, chest pain or fainting without explanation. Using clinical probability assessment, D-dimer test and helicoidal computed tomography, a reliable diagnostic conclusion is usually easy to obtain. When the clinical probability is low, a negative D-dimer test allows to rule out pulmonary embolism. When the clinical probability is high, D-dimer test is not indicated and an anticoagulation must be initiated while awaiting the outcome of diagnostic tests. In such cases or when D-dimer test are positive, multi-detector computed tomography can confirm or exclude the diagnosis in most of the cases. If there is a remaining suspicion or when computed tomography is contraindicated, leg vein ultrasonography and/or lung scintigraphy should be performed. The treatment is based on a risk stratification using clinical parameters (Pulmonary Embolism Severity Index) and, if necessary, biomarkers and right ventricular evaluation. For patients with hemodynamic compromise, short-course thrombolytic therapy is indicated followed by unfractionated heparin. In patients with normal systemic arterial pressure but poor prognostic indicators, fibrinolysis is controversial but unfractionated heparin is preferable. In others patients without severity indicator, low weight molecular heparin or fondaparinux is recommend for at least 5 days with initiation of vitamine K antagonists and elastic compression stocking on the first treatment day. Early ambulation is desirable.