The American College of Physicians “best practice advice” for suspected pulmonary embolism

Pulmonary Embolism

The recommendations, based on a literature review and the best available evidence, include:

  • Use validated prediction rules (e.g., Wells or Geneva tools) to estimate a patient’s pretest probability of acute PE.
  • For patients with a low pretest probability who also meet all Pulmonary Embolism Rule-Out Criteria (PERC), neither D-dimer testing nor imaging should be performed. The PERC comprise eight variables (see link below).
  • For patients with an intermediate pretest probability or those who do not meet all PERC, perform high-sensitivity D-dimer testing; imaging should not be done initially.
  • For those over age 50, use age-adjusted D-dimer thresholds (instead of the usual 500 ng/mL) to decide whether to proceed to imaging; patients with a low-age-adjusted level should not undergo imaging.
  • For patients with a high pretest probability of PE, forego D-dimer testing and go straight to computed tomographic pulmonary angiography. If CTPA is contraindicated or unavailable, ventilation-perfusion lung scanning may be used.

 

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Cancer Emergencies

  1. Leukostasis occurs with WBC count greater than 50,000 with symptoms (usually 100,000), predominantly pulmonary and neurologic symptoms.80% of patients will have fever, so treat for infection concurrently. Chemotherapy is the only treatment that decreases mortality, but if not available, leukopheresis is the next step.
  2. Neutropenic fever is defined as a single oral temperature greater than 38.3 oC or temperature >38.0 oC for one hour, with absolute neutrophil count (ANC) of < 1500 cells/microL, with severe defined as an ANC less than 500 cells/microL or an expected drop to < 500 over 48 hours. 30% of fevers are due to infection, with gram positives accounting for 60% of infections. Broad coverage targeting gram positives and pseudomonas is needed.
  3. Venous Thromboembolism (VTE) (DVT, Pulmonary Embolism (PE))is common in cancer, with 15% of patients with malignancy experiencing DVT/PE. Khorana score is validated for VTE risk stratification in this patient population. CT PE and DVT US are the best tests. Anticoagulation with heparin has the best literature support for treatment.

Serious reasons why your patient fainted…

If your patient presents with…

  1. Symptoms of arm ischemia or paresthesias with syncope – Subclavian steal syndrome
  2. Chest pain that is acute, radiates, tearing/sharp, involves symptoms above and below diaphragm with syncope – Aortic dissection
  3. Tachypnea, pleuritic chest pain, shortness of breath with syncope – PE
  4. Neurologic deficit with syncope – TIA/stroke
  5. Headache that is sudden in onset, maximal at onset, worst of life with syncope – Subarachnoid hemorrhage
  6. Minor trauma with head or neck pain and syncope – Carotid/vertebral artery dissection
  7. Abdominal/flank pain in older patient with syncope – Ruptured AAA

EM Don’ts

  1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
  2. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.
  3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis.
  4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.
  5. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones.