# Bypassing D-dimer Testing in Suspected High-Risk Pulmonary Embolism in the Emergency Department: A Case Report

## TL;DR

A 74-year-old man with suspected high-risk pulmonary embolism received immediate imaging instead of waiting for D-dimer test results, leading to timely treatment.

## Contribution

This case report demonstrates bypassing D-dimer testing in high-risk pulmonary embolism to expedite diagnosis and treatment.

## Key findings

- Immediate CTPA was performed without D-dimer testing due to high clinical suspicion of PE.
- Imaging confirmed extensive bilateral emboli and right ventricular strain.
- The case emphasizes the importance of clinical judgment over laboratory delays in unstable patients.

## Abstract

Pulmonary embolism (PE) remains a leading cause of sudden hemodynamic deterioration and death in emergency department patients. Although diagnostic algorithms frequently incorporate D-dimer testing, in patients with high clinical probability or hemodynamic instability, definitive imaging should not be delayed. We report a case of a 74-year-old man presenting with syncope, hypoxemia, and hypotension, in whom immediate computed tomography pulmonary angiography (CTPA) was performed without prior D-dimer testing due to strong clinical suspicion of high-risk PE. Imaging revealed extensive bilateral pulmonary emboli with radiological signs of right ventricular strain, which were subsequently supported by point-of-care echocardiography. Due to recent head trauma, systemic thrombolysis was contraindicated, and the patient was referred for urgent mechanical thrombectomy. This case highlights the importance of clinical judgment and early imaging in high-risk PE and emphasizes that laboratory testing should not delay life-saving diagnostic and therapeutic decisions in unstable patients.