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    Geneva Score (Revised) for Pulmonary Embolism

    Objectifies risk of PE, like Wells’ score.
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    When to Use
    Pearls/Pitfalls
    Why Use

    The rGeneva can risk-stratify patients into low, intermediate or high risk based on history and physical exam alone. Many use it as an alternative to the Wells’ PE criteria to determine those patients that are low enough risk to rule out pulmonary embolism with a d-dimer serum test and avoid the use of CT angiography and ultrasound.

    The Revised Geneva Score (rGeneva) risk-stratifies patients for pulmonary embolism (PE).

    • The original Geneva score was criticised for inclusion of both a Chest X-ray and arterial blood gas to be applied; the rGeneva does not include these.
    • rGeneva is not meant to diagnose but to guide workup and testing by predicting pre-test probability of PE
    • The rGeneva score does not require imaging or serum studies for risk stratification
    • The rGeneva score does not require clinical gestalt (present in Wells’ PE criteria and often subjective) for risk stratification.
    • Physicians continue to have a low threshold for the workup of pulmonary embolism.
    • The rGeneva score aids in the reduction of unnecessary imaging studies by identifying low risk patients who can be ruled out for PE with a d-dimer serum test.
      • One study suggested a clinical decision rule + d-dimer protocol could reduce imaging by 30%.
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    < 75
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    ≥ 95
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    Creator Insights

    Advice

    The rGeneva score is an accepted alternative to the Wells’ PE criteria used to risk-stratify patients with concern for PE. This tool does not incorporate gestalt, which some would argue is better than any clinical decision rule.

    Management

    In the setting of concern for possible PE:

    • The patient is considered low risk (Score 0-3), <10% incidence of PE.
    • The patient is considered intermediate risk (Score 4-10)
      • If d-dimer testing is negative consider stopping workup.
      • If d-dimer testing is positive consider CT and US
        • If CT is inconclusive consider V/Q scan or angiography
    • If the patient is considered high risk (score 11+) (>60% incidence of PE) consider CT and US
      • If imaging is negative consider angiography

    Critical Actions

    • No decision rule should trump clinical gestalt. High clinical suspicion for PE should warrant imaging regardless of Geneva score.
    • Never delay resuscitative efforts for diagnostic testing, especially in the unstable patient.
    • History and exam should always be performed prior to diagnostic testing.
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    About the Creator
    Dr. Grégoire Le Gal
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