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.
Tag Archive for: Pulmonary Embolism
Background: Anyone who has run a code, knows that pulseless electrical activity (PEA) during cardiac arrest has a worse prognosis compared to patients with shockable rhythms. In patients with suspected massive PE as the cause of their cardiac arrest the Advanced Cardiac Life Support (ACLS) and American Heart Association (AHA) guidelines do recommend consideration of thrombolytics. There is however, no uniform consensus on the type, dose, duration, timing, or method of administration. The current study (PEAPETT Trial) was an attempt to do exactly that. Read more →
Background: The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED). It wasn’t too long ago that all patients diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE) would be admitted for anticoagulation. Some of the reasons for this were lack of literature to support outpatient therapy in the US, inability to arrange outpatient follow up, and, of course, medicolegal concerns. Dr. Jeff Kline, one of the thought leaders in VTE, advocates for the outpatient treatment of “low-risk” patients using a modified Hestia criteria supplemented with additional criteria (POMPE-C) for patients with active cancer. This publication is the initial results of his rivaroxaban-based treatment protocol. Read more →
Submassive pulmonary embolism (PE) is responsible for approximately 20% of all PEs. Although the in-hospital mortality has been reported as about 5%, there is significant morbidity associated with this diagnosis such as chronic pulmonary hypertension, impaired quality of life, persistent right ventricular disfunction, and recurrent venous thromboembolism. The literature suggests that systemic thrombolytics can improve morbidity and maybe mortality, but this comes at the risk of increased major bleeding and intracranial hemorrhage (2 – 3%) when compared to anticoagulation alone. Read more →
Background: Syncope is a very frustrating chief complaint for many in the medical field. There is no gold standard test and no validated decision instrument. It represents about 3 – 5% of ED visits, 1 – 6% of hospital admissions, and in patients over the age of 65 years it is the 6th most common cause of hospitalization . Additionally, both ED and inpatient work ups are notoriously low yield for finding significant pathology. Pulmonary embolism is one of the myriad of diagnoses included in the differential diagnosis of syncope, but there is little information looking at its prevalence amongst hospitalized patients. Fast forward to Oct. 20th, 2016 and there is now some evidence just published in the NEJM: The PESIT Trial. Read more →