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 →
Background: When evaluating therapeutic options for PE, there are three categories in my mind: Subsegmental, Submassive, and Massive. For simplicity sake lets just say subsegmental PEs get treated with anticoagulation and massive PEs get treated with thrombolysis. The submassive category is a bit trickier. For example the PEITHO trial looked at full dose systemic fibrinolysis, tenecteplace in intermediate-risk pulmonary embolism and found a reduced risk of death or cardiovascular collapse by 56% but this was offset by an almost 5-fold increased risk of major bleeding and 10-fold increased risk of intracranial hemorrhage compared to anticoagulation alone. The MOPETT Trial on the other hand, looked at half dose systemic tPA for submassive PE and found that there was a significant reduction in pulmonary artery systolic pressures at 28 months vs usual care, with no increase in intracranial hemorrhage but failed to show any statistical mortality benefit compared to anticoagulation alone. Maybe a more simple answer to the submassive PE group would be to do catheter directed thrombolysis at lower doses than given with systemic fibrinolysis. Read more →
D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article. Read more →
Typically, the treatment of acute pulmonary embolism consists of administration of unfractionated heparin or low molecular weight heparin (i.e. enoxaparin) overlapped with vitamin K antagonists (i.e. warfarin). This can be a very effective treatment regimen, but also very complex. New direct Xa inhibitors are being used more and more in clinical practice with prevention of venothromboembolism (EINSTEIN-DVT Trial), after major orthopedic surgery (RECORD1 Trial), prevention of stroke in patents with atrial fibrillation (ROCKET-AF Trial) , and in the treatment of acute coronary syndromes. Recently, the EINSTEIN-PE Trial evaluated oral rivaroxaban for treatment of symptomatic pulmonary embolism. Read more →
D-dimer testing is sensitive for thrombus formation, and in patients who are not high risk, this test is used to rule-out venous thromboembolism. D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. Specificity can range from 49 – 67% in patients ≤ 50 years of age, but in older patients (i.e. ≥ 80 years of age) the specificity is quoted as 0 – 18%. The result of this is, older patients often have more diagnostic imaging, but a higher cut-off may lead to increased false negative cases (i.e. missed VTE) and make this strategy less safe. So could age adjusted d-dimer testing increase specificity without affecting sensitivity?
Abnormal vital signs are poor predictors of mortality associated with pulmonary embolism (PE). Diagnosis of PE and right ventricular (RV) strain with transthoracic echocardiography (TTE) however, has been well documented as a predictor for pending shock and significant in-hospital mortality. One study done by Grifoni S et al, showed that 10% of normotensive patients with PE and RV strain on echo developed PE related shock, and 3% died, whereas normotensive patients without signs of RV strain remained hemodynamically stable.
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