Wells’ score for early prehospital screening of pulmonary embolism

Pulmonary embolism (PE) represents a significant health problem due to non-specific clinical features and a high risk of lethal outcome. PE diagnostics can some-times be very difficult, especially at the prehospital level. We present a patient in whom early screening for PE at the pre-hospital level, performed using the Wells’ Score, was a life-saving event.

Case scenario: the Emergency Medical Service (EMS) received a call regarding a male, aged 27 years, who was unconscious. Prior to losing consciousness, he com-plained of suffocation and tachycardia. Ten days earlier he sustained an injury to the knee which was immobilized with a splint, followed by bed rest. A year ago he was examined for chest pain, hypertension and tachycardia. On examination the pa-tient was conscious, well oriented, eupneic, afebrile, with normal skin color. On pul-monary auscultation breath sounds were normal, and oxygen saturation was 90%. Findings on cardiac examination includ-ed: regular rate and rhythm, no murmur, blood pressure (BP) 120/85mmHg on both arms. ECG revealed sinus rhythm, rate of 100 beats/min, discreet signs of right heart strain (S1Q3T3 pattern), negative T wave from V1-V4, ST depression in D2, D3, AVF. A Wells’ score of 6 (most probably PE) was calculated: immobilization for 4 weeks – 1.5 points, tachycardia (pulse 120/min) – 1.5 points and alternative diagnosis less probable than PE – 3 points. The pa-tient was suspected of PE and referred to a cardiologist.

Conclusion. Pulmonary embolism often remains undiagnosed during a patient’s lifetime or is erroneously diagnosed. The significance of the scoring of each patient aimed at the recognition of pulmonary embolism at the prehospital level cannot be underestimated.

pulmonary embolism, prehospi-tal level, Wells’ Score

1. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. The Task Force for the Diagnosis, Management of Acute Pulmonary Embolism of the European Society of Cardiology. 2014 ESC Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3033–80. doi:10.1093/eurheartj/ehu283.

2. Wells PS, Anderson DR, Rodger M. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000 Mar;83(3):416-20.

3. Menaker J, Stein DM, Scalea TM. Incidence of early pulmonary embolism after injury. J Trauma 2007;63(3):620–4.

4. Rogers FB, Osler TM, Shackford SR. Immediate pulmonary embolism after trauma: case report. J Trauma 2000 Jan;48(1):146–8.

5. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emer-gency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 2011;57(6):700–6.

6. Demircan A, Aygencel G, Keles A, Ozsoylar O, Bildik F. Pulmonary embolism presenting as syncope: a case report. J Med Case Repor 2009;3:7440. doi: 10.4076/1752-1947-3-7440.

7. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et al. Venous thromboembolism (VTE) in Europe. The num-ber of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756–64.

8. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embo-lism diagnosis (PIOPED). JAMA 1990; 263(20):2753–9.

9. Shen JH, Chen HL, Chen JR, Xing JL, Gu P, Zhu BF. Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis. 2015 Jul 16. [Epub ahead of print]