This chapter discusses the diagnosis, evaluation and management of pulmonary embolism (PE). The evaluation for suspected PE is tailored to the level of the clinician's suspicion for this diagnosis based on the patient's history, physical examination, and risk factors. A chest radiograph is rarely diagnostic for PE, but can identify alternative diagnoses. Hampton's hump, a pleural-based, wedge-shaped area of infiltrate, can be seen in pulmonary infarction and is suggestive of PE. Patients diagnosed with PE should be started on anticoagulation unless otherwise contraindicated to prevent clot propagation. Patients with a high clinical probability of PE should be started on anticoagulation therapy while awaiting diagnostic confirmation. The most common causes for sudden decompensation are respiratory and hemodynamic as the result of sudden shift or increase in clot burden. Intubation may be necessary to improve oxygenation/ventilation and establish control of the airway of the patient with PE.

The chest radiograph (CXR) is the most commonly ordered plain film in emergency medicine and has correspondingly broad indications. Patients who complain of chest pain have a broad differential diagnosis, and CXR is one of the first screening tests to be applied in chest pain complaints. CXR is useful to diagnose or identify primary cardiac and pulmonary pathology, abnormal pleural processes, thoracic aortic dilation, aspirated foreign bodies, and thoracic trauma. Pleural processes such as pleural thickening, pneumothorax, hemothorax, and pleural effusions are evident on CXR. CXR is the first radiologic screening test for thoracic aneurysm. Skeletal injuries, including rib, scapular, clavicular, shoulder, and sternal fractures and dislocations, can be seen on CXR. CXR identifies lung masses, pleural lesions, air-space disease, and hilar masses. However, the quality of these lesions is better delineated by CT. A consistent approach to the CXR improves detection of pathology.