Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions. Read more →
Tag Archive for: PE
EM Journal Update: Safety of Using Wells’ Clinical Model With D-Dimer To Manage Patients In The ED With Suspected Pulmonary Embolism
Background: In the US, pulmonary embolism (PE) kills 100,000 people each year and over 360,000 new cases of PE are diagnosed each year (Horlander 2003). Currently, the gold standard for diagnosing PE is the computed tomographic pulmonary angiography (CTPA). Patients with PE present with varying symptoms, from anxiety and tachycardia, to shortness of breath and syncope. Thus, it is difficult to exclude this life-threatening diagnosis and thus far there is no validated method to exclude PE. Prior work from this group derived and validated Wells’ criteria for calculating clinical probability of PE, and using it to determine which patients should get serial ultrasonography, venography, or angiography after an equivocal ventilation perfusion (VQ) scan (Wells 1998). Now, this group examines how the D-dimer assay, together with Wells’ clinical model can help manage PE patients. Read more →
Background: Pulmonary embolism is the leading cause of death in pregnancy and the puerperium – accounting for nearly 20% of maternal deaths in the United States – making rapid and accurate diagnosis critically important for emergency physicians, OB/GYNs, and all who take care of these women on a regular basis. Unfortunately, typical diagnostic pathways and approaches may not apply in pregnancy, and are made more complicated by the frequency of concerning and suggestive signs and symptoms in this population, particularly dyspnea (a common symptom in pregnancy related to an increase in progesterone levels) and tachycardia (as resting heart rate is typically expected to increase by up to 25% in normal pregnancy). Read more →
The PERC rule has been a welcome addition to the emergency department evaluation of patients with chest pain or dyspnea suspected of pulmonary embolism. This has allowed a reduction in D-dimer testing in low risk patients. The traditional saturation cut-off of 95% can pose a challenge for patients seen at higher elevations where mild hypoxemia can be a normal physiologic parameter. At these elevations patients can flunk the PERC rule due to borderline hypoxemia with oxygen saturation levels in the 93-94% range, despite all other PERC rule criteria being negative. This can result in D-dimer testing and the associated risk of unnecessary CT radiation exposure in the event of a false positive D-dimer.
Background: In patients with symptoms of pulmonary embolism (PE), we often turn to vital signs, including heart rate, respiratory rate and pulse oximetry, as part of our initial impression of the patient. Before even considering further testing, such as d-dimer or CTPA, we look first at the vital signs to form our gestalt impression of the patient. Clinical decision making tools are utilized in one static point in time, but gestalt decision-making occurs over the course of the patient’s entire stay in the Emergency Department (ED). Because of this, clinicians may use changes in vital signs to augment their differential diagnosis or to justify their belief that a PE work up is not necessary.