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Pulmonary Embolism 際際滷 from Emergency Medicine Institute Case Study

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John Bielinski

This document discusses pulmonary embolism (PE), including: 1) The most common complaint is shortness of breath, but dyspnea occurs in 73% of cases. The best initial test is CT angiogram. Treatment is anticoagulation. 2) Signs of PE include leg findings like swelling in 47% of cases and tachycardia in 24% of cases. 3) The Wells Criteria and PERC rules help determine pre-test probability of PE. A negative D-dimer test is useful to rule out PE in low probability patients, though the test has many false positives.

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Pulmonary Embolism John Bielinski www.Emergency-Medicine-Institute.com
Whats Inaccurate About PEs? Most common complaint = SOB Most common EKG finding = S1Q3T3 Most common ABG = R. Alkalosis Risk factors = Virchows Triad Best initial test = CTA Definitive test = Angiogram CXR Findings = Wedge shaped pleural density or a central black area (Plus non-specific findings) Hamptoms Hump or Westermarks Sign Treatment = Anticoagulation
Which is incorrect? A. SOB B. S1Q3T3 C. R. Alkalosis D. CTA E. Anticoagulation
Dyspnea 73% Pleuritic pain 66% Cough 37% Orthopnea 28% Calf or thigh pain and/or swelling 44% Wheezing 21% Hemoptysis 13% Stein PD et al Chest. 1991;100(3):598. Symptoms of PE
Leg findings 47% Calf or thigh swelling, erythema, edema, tenderness, palpable cords Tachycardia 24% Rales 18% Decreased breath sounds 17% JVD 14% Fever mimicking pneumonia 3% Stein PD et al Chest. 1991;100(3):598. Signs of PE
Wells Criteria Sign of or Hx of DVT 3 Points PE your number one thought? 3 Points Tachycardia 1.5 Points Immobilization 1 Points Hemoptysis 1 Points Cancer 1 Points
Score >6.0 High Probability 59% Score 2.0 to 6.0 Moderate Probability 29% Score <2.0 Low Probability 15% Stein PD et al Radiology. 242 (1): 1521. doi:10.1148/radiol.2421060971. PMID 17185658. Wells Criteria
PERC RulesPulmonary Embolism Rule Out Criteria <50?
Pulmonary Embolism 際際滷 from Emergency Medicine Institute Case Study
PERC Rules Vital Signs (normal) Virchows Triad Hemoptysis Age < 50 DVT? <50
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Cochrane Data Regarding D. Dimers Limited evidence Few false-negatives Very high levels of false-positive This makes the test useful as a rule-out test but means that a positive result requires diagnostic imaging
Authors Conclusions: A negative D-dimer test is valuable to rule out PE with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D-dimer results for those over the age of 65 years.
Chest or Pulmonary Symptoms? Document on your charts: 100% of the time!!! 1) Arterial risk factors 2) Venous risk factors - Virchows Triad 3) Symmetrical legs - No Homans Sign

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Pulmonary Embolism 際際滷 from Emergency Medicine Institute Case Study

  • 2. Whats Inaccurate About PEs? Most common complaint = SOB Most common EKG finding = S1Q3T3 Most common ABG = R. Alkalosis Risk factors = Virchows Triad Best initial test = CTA Definitive test = Angiogram CXR Findings = Wedge shaped pleural density or a central black area (Plus non-specific findings) Hamptoms Hump or Westermarks Sign Treatment = Anticoagulation
  • 3. Which is incorrect? A. SOB B. S1Q3T3 C. R. Alkalosis D. CTA E. Anticoagulation
  • 4. Dyspnea 73% Pleuritic pain 66% Cough 37% Orthopnea 28% Calf or thigh pain and/or swelling 44% Wheezing 21% Hemoptysis 13% Stein PD et al Chest. 1991;100(3):598. Symptoms of PE
  • 5. Leg findings 47% Calf or thigh swelling, erythema, edema, tenderness, palpable cords Tachycardia 24% Rales 18% Decreased breath sounds 17% JVD 14% Fever mimicking pneumonia 3% Stein PD et al Chest. 1991;100(3):598. Signs of PE
  • 6. Wells Criteria Sign of or Hx of DVT 3 Points PE your number one thought? 3 Points Tachycardia 1.5 Points Immobilization 1 Points Hemoptysis 1 Points Cancer 1 Points
  • 7. Score >6.0 High Probability 59% Score 2.0 to 6.0 Moderate Probability 29% Score <2.0 Low Probability 15% Stein PD et al Radiology. 242 (1): 1521. doi:10.1148/radiol.2421060971. PMID 17185658. Wells Criteria
  • 10. PERC Rules Vital Signs (normal) Virchows Triad Hemoptysis Age < 50 DVT? <50
  • 11. -
  • 12. Cochrane Data Regarding D. Dimers Limited evidence Few false-negatives Very high levels of false-positive This makes the test useful as a rule-out test but means that a positive result requires diagnostic imaging
  • 13. Authors Conclusions: A negative D-dimer test is valuable to rule out PE with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D-dimer results for those over the age of 65 years.
  • 14. Chest or Pulmonary Symptoms? Document on your charts: 100% of the time!!! 1) Arterial risk factors 2) Venous risk factors - Virchows Triad 3) Symmetrical legs - No Homans Sign