PE and Thee.

[RustedFox]

Apologies for the thread title. I had an attending back during residency who gave a talk about PE entitled the same, and not only was the talk awesome, but the guy is awesome. My little homage.

To the students looking to get into EM, and to the residents honing their skills, and to my fellow attendings:

Consider PE in EVERY patient with a complaint above the umbilicus. My last 2 PEs had zero components of chest pain, SOB, or pleuritic symptoms.

1.) 65 year old female from nursing home, sent for coffee-ground emesis and neck pain. Sinus tach to 104 BPM. No SOB, No CP. Just moans that she doesn't feel good. Advanced diabetic neuropathy. PE.

2.) 73 year old male with fever to 102.1 and thoracic back pain. No chest pain. No risk factors. Not even tachycardic. PE.


Post your zebra PE stories here, y'all.

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[future_dr_house]

So why did you even consider PE in the first patient? Did you do a dissection scan and find a PE? Do you cta people just for the hell of it? Was it massive, segmental, or sub segmental?


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[gman33]

The academic answer would be that those cases were likely false positives.

The real world answer would be to never rely on patient history.

Coffee ground emesis is bs.
Just as likely that was hemoptysis, or never even occurred. Plus they were tachycardia.

Case 2. Thoracic back pain in the elderly is a disaster until proven otherwise. I'd be glad I found a pe, and not ad or abscess.

There was a reason you went looking.
Nice job.

The real problem comes when you go looking for no real reason and get that subsegmental read that is probably bogus.

 

[GeneralVeers]

Were these subsegmental PEs or massive saddle emboli? I the case of these subsegmental PEs, I think we will eventually conclude that they are physiologic and we are harming/killing people by putting them on anticoagulants.

 

[StephBee]

I had a 20something guy come in "not feeling right" and slightly tachy. (110's). Massive saddle PE and a atrial thrombus. He postponed thrombectomy until he started having runs of SVT

 

[southerndoc]

Midde-aged guy traveled from FL back to GA by air. Pleuritic CP, dyspnea. No tachypnea or hypoxemia. D-dimer NEGATIVE. Saddle PE.

 

[WilcoWorld]

51 yo man presents with RUQ pain. Normal BP, temp, and O2 sat. HR was high 90's, but <100. On exam, with deep palpation of the RUQ on inspiration he says, "yeah, that's where it hurts", but Murphy's is equivocal.

LFT's + US are normal. Yet the guy seems to be legitimately still in pain.

So...51 = PERC non-negative + a modicum of clinical suspicion = head scratch-->elevated d-dimer-->CT ordered--> significant embolism and RLL pulmonary infarct.

It was a long workup, but at least by that time the patient was tachycardic and tachypneic, so admission was a cinch.

 

[RustedFox]

So why did you even consider PE in the first patient? Did you do a dissection scan and find a PE? Do you cta people just for the hell of it? Was it massive, segmental, or sub segmental?

The best answer that I can give you is this: she was largely bed-bound and "looked sick", so I followed the little white rabbit (big white rabbit?) down the dimer-hole. Segmental PE in the LLL region.

 

[RustedFox]

The academic answer would be that those cases were likely false positives.

The real world answer would be to never rely on patient history.

Coffee ground emesis is bs.
Just as likely that was hemoptysis, or never even occurred. Plus they were tachycardia.

Case 2. Thoracic back pain in the elderly is a disaster until proven otherwise. I'd be glad I found a pe, and not ad or abscess.

There was a reason you went looking.
Nice job.

The real problem comes when you go looking for no real reason and get that subsegmental read that is probably bogus.

Regarding the emesis... here's the real pisser. She was sent by her ECF to a different hospital earlier in the day, who CT'ed her and sent her back once she was done vomiting. She vomited again at her ECF, so they sent her up the road to my shop instead. I too, felt that it was BS until she spewed coffee-grounds in front of me.

 

[RustedFox]

Three PE's ago, my patient's D-Dimer value was 6.66.

That wasn't good, either.

 

[shoal]

Please only order ddimer in low risk patients. Its negative predictive value is not very good. I was taught npv of about 60 percent. Negative ddimer on someone you think pe and has any other wells criteria is pretty much a no go. I had a case the other day. 60yo M hx of etoh admitted previous weeks for new onset aflutter, persistent sob, normal vs. Got him up tachyd to 150s. Ddimer positive bl numerous subsegmental pes. Thought he was just failure from no atrial kick.

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[USCDiver]

Regarding the emesis... here's the real pisser. She was sent by her ECF to a different hospital earlier in the day, who CT'ed her and sent her back once she was done vomiting. She vomited again at her ECF, so they sent her up the road to my shop instead. I too, felt that it was BS until she spewed coffee-grounds in front of me.

Load her ass up with anticoagulants!

 

[GeneralVeers]

So the moral of this thread is that regardless of D-dimer or symptoms, everyone should get a CTA chest to rule out PE?

 

[The White Coat Investor]

Post your zebra PE stories here, y'all.

Sign-out two days ago- lady who had a cough, was quite wheezy initially and sounds like bronchitis. CXR negative. "I gave her a few nebs and now she's hypoxic. Since she wasn't initially, it's probably V:Q mismatch from the albuterol. Watch her for a little bit and I bet her hypoxia will resolve and you can discharge."

Well, her hypoxia didn't resolve, so I launched into the pre-admission work-up- Trop, EKG, d-dimer, BNP etc. D-dimer 1.5 (normal here <0.5) so I scanned her. Bilateral PEs. Started having chest pain 3+ hours into the ED stay.

Moral of the story- Don't be afraid to sit on someone for a little bit. Lots of disease doesn't become obvious for a few hours. In the same sign-out was a 33 year old chest pain patient, only risk factor was smoking, whose second trop came back positive. The doc hadn't even wanted me to send him for an outpatient stress- that's how unworried he was!

 

[RustedFox]

Sign-out two days ago- lady who had a cough, was quite wheezy initially and sounds like bronchitis. CXR negative. "I gave her a few nebs and now she's hypoxic. Since she wasn't initially, it's probably V:Q mismatch from the albuterol. Watch her for a little bit and I bet her hypoxia will resolve and you can discharge."

Well, her hypoxia didn't resolve, so I launched into the pre-admission work-up- Trop, EKG, d-dimer, BNP etc. D-dimer 1.5 (normal here <0.5) so I scanned her. Bilateral PEs. Started having chest pain 3+ hours into the ED stay.

Moral of the story- Don't be afraid to sit on someone for a little bit. Lots of disease doesn't become obvious for a few hours. In the same sign-out was a 33 year old chest pain patient, only risk factor was smoking, whose second trop came back positive. The doc hadn't even wanted me to send him for an outpatient stress- that's how unworried he was!

This is why I left my HCA job. Metric mandates would have gotten me to push this guy out the door. "Door to discharge less than two hours!" they scream.

Eff that. Doctors gotta doctor.

 

[RustedFox]

So the moral of this thread is that regardless of D-dimer or symptoms, everyone should get a CTA chest to rule out PE?

Noooo, gramps. Moral of the story is: PE has a wide variety of varied presentations. Take a few to think about it.

 

[Janders]

Negative DDIMER = saddle is old hat
Negative PERC = saddle is yawnie.

I had left CVA TTP (mild) with colicky left flank pain associated with nausea and vomiting, improved with toradol, zofran, IVF. HR 110s. Otherwise pretty darned healthy young person, thought it was renal colic like her sister got the year prior. Dry CT belly negative for Stone. Went back in to discharge her (?passed stone) and noticed tachypnea without hypoxia. Got the CTA, left main PE large clot burden inferiorly, right heart strain, etc.

That was as a senior resident. I saw 2 more that year that presented as "flank pain" likely renal colic... with a heightened awareness you could find the subtly-- a bit of pleuritic pain, a whiff of hypoxia.

 

[EKGdoc]

It's like syphilis- they don't call it the great imitator for nothing.

 

[thorg12]

Ok have to put my plug in for management of PE.
Let me preface this with I do anticoagulant the PE's that I find and occasionally have TPA'd some.
I just want to throw it out there that there is NO evidence to support anticoagulation in PE; its dogma that has been passed down for decades; the ONE study(NSAID vs heparin) is from 1960.
Im not saying some people don't benefit from anticoagulation but I'm sure everyone with a PE does NOT benefit.
medico legally its a whole different story; just don't want people fooled into thinking giving heparin is doing something for that person's PE

cochrane review saying there is not enough evidence
http://www.cochrane.org/CD003746/PV...r-treating-people-who-have-venous-blood-clots

true mortality of untreated pe in the ED
http://rtjournalonline.com/The Mort...Embolism in Emergency Department Patients.pdf

 

[deleted109597]

Ok have to put my plug in for management of PE.
Let me preface this with I do anticoagulant the PE's that I find and occasionally have TPA'd some.
I just want to throw it out there that there is NO evidence to support anticoagulation in PE; its dogma that has been passed down for decades; the ONE study(NSAID vs heparin) is from 1960.
Im not saying some people don't benefit from anticoagulation but I'm sure everyone with a PE does NOT benefit.
medico legally its a whole different story; just don't want people fooled into thinking giving heparin is doing something for that person's PE

cochrane review saying there is not enough evidence
http://www.cochrane.org/CD003746/PV...r-treating-people-who-have-venous-blood-clots

true mortality of untreated pe in the ED
http://rtjournalonline.com/The Mortality of Untreated Pulmonary Embolism in Emergency Department Patients.pdf

Agree wholeheartedly.
Remember, we diagnose a whole lot more of them, but the same numbers of them die. It has nothing to do with "doctors gotta doctor", whatever the hell that means. All scanning and "treating" does is keep the lawyers off of you (maybe). Just like in stroke. Nothing we do in the ED helps stroke to the same degree that physical therapy and speech therapy does.
By all means, do as you see the patient needs, but don't delude yourself into thinking you're helping the patient by doing this. Or by giving Penicillin to strep throat. Or tPA to strokes. Or oxygen to MIs. Or by starting pressors. Or....

 

[gman33]

I hate the d-dimer.
There is no great data on this, but if it's been going on for more than 5-7 days, good chance the d-dimer will be negative even with a clot.
We all know how good patients are at providing an accurate history.
Plus they could have had a subclinical clot.

If I really think they have any realistic chance, they get an image.
Very rarely do I order a d-dimer.

Anticoagulating the subsegmental clot probably results in more harm.
Until the major organizations recommend otherwise, we are stuck where we are.

 

[RustedFox]

"Doctors gotta doctor" was in specific reference to the pressures of admin to make the metrics look good. Its the reason why I quit my HCA job. I mean to say: "Take the time to stop, think, and do the right thing." i.e.- be a Doctor and not some administrate pointdexter.

 

[Old_Mil]

Old. Back pain.

Saw PMD. Given hydrocodone.

Saw ortho. MRI spine appropriate for age.

D-dimer 21.

Bilateral emboli

 

[GeneralVeers]

My point was more of a question. Should we be ruling out PE on everyone with bizarre symptoms for which everything else comes back normal? That's gonna make for a huge spike in negative CTAs.

 

[southerndoc]

My point was more of a question. Should we be ruling out PE on everyone with bizarre symptoms for which everything else comes back normal? That's gonna make for a huge spike in negative CTAs.

I pretty much either send a D-dimer or CTA any patient with chest pain or shortness of breath unless it is clearly something else (classic anginal symptoms with high-risk for ACS, asthma exacerbation with a lot of wheezing, pneumonia diagnosed on CXR and symptoms to fit it, etc.).

 

[xaelia]

In a world of zero-miss, chasing these fun zebras by tossing a D-dimer at all chest pains and CTAing weird-looking flank pains is all fine and dandy.

Just remember you're doing more harm than good via the test itself, and by detecting pseudodisease and false-positives. There's a reason why PERC was built around a 1.8% acceptable miss rate, and that didn't even fully account for the poor specificity of CTPA.

I'm comfortable letting some of these strange ones get away secure in the knowledge I'm not doing any net harm. Then again, I'm also in a non-RVU system that relatively incentivizes high-value care.

 

[bravotwozero]

Old. Back pain.

Saw PMD. Given hydrocodone.

Saw ortho. MRI spine appropriate for age.

D-dimer 21.

Bilateral emboli

were you doing a cta to rule out dissection or embolus?

 

[Old Grunt]

Were these subsegmental PEs or massive saddle emboli? I the case of these subsegmental PEs, I think we will eventually conclude that they are physiologic and we are harming/killing people by putting them on anticoagulants.

The only thing this post is missing is a mic drop. I couldn't agree more (for whatever my opinion is worth).

One relevant PE I did catch the other day that would have been a mess otherwise (I believe) was a large saddle embolus parading as a pneumonia. The patient had recently been hospitalized and was now having fevers, productive cough, dyspnea, mild hypoxia and a large infiltrate on XR. However, she also had severe pleuritic pain on inspiration so I scanned her and found the PE. Glad I didn't just start antibiotics and send her to the floor.

 

[da8s0859q]

The only thing this post is missing is a mic drop. I couldn't agree more (for whatever my opinion is worth).

One relevant PE I did catch the other day that would have been a mess otherwise (I believe) was a large saddle embolus parading as a pneumonia. The patient had recently been hospitalized and was now having fevers, productive cough, dyspnea, mild hypoxia and a large infiltrate on XR. However, she also had severe pleuritic pain on inspiration so I scanned her and found the PE. Glad I didn't just start antibiotics and send her to the floor.

Just curious -- other than pleuritic pain, what reason did this person have to end up having a PE? History of clots, OCPs, something?

 

[cofcemt]

14 yo F,wheezing, long hx of asthma. Recently diagnosed with pneumonia, stated on amox 5 days ago, no improvement. Infiltrate on cxr. Temp 100F. Lots of URI symptoms. No family hx, no sickle cell, borderline hypoxic. Better after nebs. I got busy and by the time I got back to discharge looked like she did before. Called peds to admit for refractory asthma.

During admission, mom spontaneously remembered she has had 2 PEs and a DVT and so has her mother...14 yo with saddle PE.

 

[goodoldalky]

I pretty much either send a D-dimer or CTA any patient with chest pain or shortness of breath unless it is clearly something else (classic anginal symptoms with high-risk for ACS, asthma exacerbation with a lot of wheezing, pneumonia diagnosed on CXR and symptoms to fit it, etc.).

PERC/Wells?

 

[fahimaz7]

Post your zebra PE stories here, y'all.

My Best PE was a 38 y/o female POD 1 after a colonoscopy here with "abdominal distension." She had a benign exam, a normal abdominal series, and normal vitals. Sent home with reassurance. Came back the next day with RUQ pain that was pleuritic. Low and behold, she had a RLL PE with infarct.

Humbling, challenging

 

[deleted547339]

PE really is the syphillis of the 21st century.

 

[turkeyjerky]

My Best PE was a 38 y/o female POD 1 after a colonoscopy here with "abdominal distension." She had a benign exam, a normal abdominal series, and normal vitals. Sent home with reassurance. Came back the next day with RUQ pain that was pleuritic. Low and behold, she had a RLL PE with infarct.

Humbling, challenging

I'm confused--are you saying that a PE caused her subjective abdominal distension? I would call B.S. on that.

Or,are you suggesting that the ED should function as a PE screening department, where every patient, in addition to a focused work up related to their presenting complaint, also gets screened for pulmonary embolism?

 

[Greenbbs]

Today.

Febrile 39.5, tachy at 125. Sick kids in the house. Really hurt in the right lower lung. Absolutely could not take a deep breath.

Cxr wasn't useful. Checked the CT because of gestalt.

Lobar PE with infarct.

 

[deleted547339]

Today.

Febrile 39.5, tachy at 125. Sick kids in the house. Really hurt in the right lower lung. Absolutely could not take a deep breath.

Cxr wasn't useful. Checked the CT because of gestalt.

Lobar PE with infarct.

39.5??

 

[Doctor Bob]

39.5??

Kelvin.

Normally they're 34.

It's a very cold house.

 

[gman33]

PEs can cause belly pain and fevers.
Sometimes there are subtle cues that point to a diagnosis outside of the box.
Do I look for PEs in all of these patients? Of course not.
But if I didn't find anything in my usual workup, I start to think about the outliers before I d/c with viral syndrome...

 

[Greenbbs]

39.5??

Yeah. The PCP thought he had pneumonia....when I told him about the PE, his exact words were 'bull****'. I had to tell him where it was on the CT on the phone while he looked at the EMR.

He then apologized and said 'holy crap, that's scary'

 

[fahimaz7]

I'm confused--are you saying that a PE caused her subjective abdominal distension? I would call B.S. on that.

Or,are you suggesting that the ED should function as a PE screening department, where every patient, in addition to a focused work up related to their presenting complaint, also gets screened for pulmonary embolism?

I think her upper abdominal pain/distension/discomfort was her PE in progress. She infarcted the lower lobe @ the level of the diaphragm. She came back within 12 hours of seeing me and was dx with a PE. Normal vitals still.

 

[daveyjwin]

Low 20s male, previous visit for mid back pain, hurts on ROM, completely normal vitals, PERC and Wells negative, no risk factors at all, returned (my visit) with hemoptysis, still normal vitals, scanned his chest, PE with LLL Infarct.

 

[deleted77919]

…

 

[WilcoWorld]

The longer I do this, the more I don't even know what to think anymore...

94yo F without significant medical probelms presened with pain in her R neck and shoulder, primarily in trapezius. Hurts to move shoulder and press on R trap. Shoulder X ray shows lung nodule. CT chest with contrast shows no nodule (just vasculature) but does show a large clot extending from the R side into the main pulmonary artery.

No chest pain. No shortness of breath. No hypoxia. No tachycardia. Heck she'd be PERC negative except for her age.

I hear ya, which is why the only muscoloskeletal pain that I'll diagnose 94 year olds with are fractures and bone mets.

 

[dotcb]

I can count on one hand (almost never) the number of times I've pursued a PE diagnosis for flank pain or abdominal pain.

Things that make me think about and look for a PE are some of the following:

chest pain, dyspnea, syncope, pleuritic symptoms, tachycardia, tachypnea, hypoxia, unexplained ST/T wave patterns, etc.

I use the PERC score, Wells criteria, D-dimer, and when I just want to get to the answer fast and/or rule out dissection at the same time – I go straight to CT.

 

[TooMuchResearch]

So not PERC negative then

 

[TheBlueBlazer]

It seems like the big take-away from here is not to CTA everyone who walks in through the door, it's to CONSIDER the possibility, and to dig a little deeper in people who just ain't acting right, and to respect comorbidities. Let your decision rules help you, realize and accept that you're going to miss some and that zero-miss medicine hurts people. Give good discharge instructions, explain your reasoning for not ordering a complete rule-out for everyone, encourage people to come back/follow up if things fail to improve or worsen, and have a good macro in your EMR that states such. And remember that while some people DO drop dead from PE, in many of them, a delay in the diagnosis is not necessarily going to hurt everybody, and it may even be a non-disease.

And of course to murky the waters, we're seeing people be more aggressive about doing more than just anticoagulating some of the larger ones seeing the consequences of the increased pulmonary hypertension. Our surgeons have become quite aggressive about doing thrombectomies in folks with a large clot burden.

 

[WilcoWorld]

Give good discharge instructions, explain your reasoning for not ordering a complete rule-out for everyone, encourage people to come back/follow up if things fail to improve or worsen.

I think that this practice is my most important form of malpractice insurance.

 

[Old Grunt]

Just curious -- other than pleuritic pain, what reason did this person have to end up having a PE? History of clots, OCPs, something?

I don't remember fully. I think it was just the recent hospitalization.

 

[bravotwozero]

So let's say clinically a patient has a dvt and very likely a PE, but vitals are normal. You find a positive dvt on ultrasound. Would you forgo the CTA since it won't change your management?


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[WilcoWorld]

So let's say clinically a patient has a dvt and very likely a PE, but vitals are normal. You find a positive dvt on ultrasound. Would you forgo the CTA since it won't change your management?


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If the patient were pregnant, than yes. If not pregnant, it depends.