Tag Archive for: Pulmonary Embolism

The Critical Pulmonary Embolism Patient

06 Nov
November 6, 2017

Background: Previously, I had given a talk on the use of thrombolytics in submassive PE in 2016. This year, I had the privilege of speaking at ACOEP 2017 again with an update on the critical pulmonary embolism patient. This post will serve as a reference for that talk.

There are many ways to classify pulmonary embolism, but the best clinical definition would depend on the hemodynamic consequences.  For example, massive pulmonary embolism can be defined as systemic hypotension (SBP < 90 mmHg or a drop in SBP of at least 40mmHg for at least 15 min) or shock (tissue hypoperfusion, hypoxia, altered mental status, oliguria, or cool clammy extremities.)  There is a second subset of patients that also warrant discussion; submassive pulmonary embolism.  These patients are defined as lack of systemic hypotension (<90mmHg), but have right ventricular dysfunction/hypokinesis. RV dysfunction tells us that there is severe pulmonary artery obstruction and impending hemodynamic failure. Read more →

The YEARS Study – Simplified Diagnostic Approach to PE

28 Sep
September 28, 2017

Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation, false positive results and the potential for contrast-induced nephropathy. The YEARS study aims to present a simplified algorithm for evaluation with a two-tiered D-dimer threshold to reduce the numbers of CTPA in all age groups. Read more →

Safety of PE Treatment with Rivaroxaban

31 Aug
August 31, 2017

Background: The simplified PE Severity Index (sPESI) is one of several validated prognostic tools for acute pulmonary embolism (PE).  The European Society of Cardiology recommended the use of the sPESI to risk-stratify patients with acute PE into low risk (sPESI=0) and non-low risk (sPESI≥1) in order to guide treatment and disposition (Konstantinides 2014).  Systematic reviews and meta-analyses have found that outpatient management of low-risk PE patients with standard therapy is safe, effective, and cost-effective (Aujesky 2011, Zondag 2013, Kahler 2015).

Standard practice in the United States for treatment of acute PE over the last decade has been a parenteral agent (e.g. enoxaparin, fondaparinux) overlapping with a vitamin K antagonist (VKA) (e.g. warfarin). However, a paradigm shift has been brewing over recent years.  Direct oral anticoagulants  (DOACs) have demonstrated efficacy as initial and long-term treatment of PE compared to standard therapy in various trials (EINSTEIN-PE 2012, RE-COVER 2014, AMPLIFY 2013, Hosukai-VTE 2013).  The EINSTEIN-PE study found that rivaroxaban was noninferior to enoxaparin/VKA for the treatment of recurrent venous thromboembolism (VTE) without increased risk of bleeding.  Rivaroxaban and other DOACs are approved for treatment of VTE in the European Union, but use in the United States of DOACs for ED treatment of PE is more limited. Read more →

Altitude Adjusted PERC Oxygen Saturation

27 Mar
March 27, 2017

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.

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Normalization of Vital Signs Does Not Reduce the Probability of Pulmonary Embolism

09 Feb
February 9, 2017

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.  

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