DVTs and PEs

[Groove]

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You do make a point about RV dysfunction and mortality, and conceivable clot in the main pulmonary artery ought to cause more RV dysfunction than a subsegmental one.

But we have all seen stable saddles and unstable segmental PE's.

And...the PESI score which, prima facie is believable, doesn't account for RV dysfunction and clot burden on CT. It looks at important stuff like hypotension, age, co-morbidities, and others.

I said it above.....I don't think location or size of clot on CT should mean that much!

I hear ya man. Regarding location of the clot... Personally, I feel clot burden and location is important and regardless of whether someone has done a tremendous amount of research on the issue and/or included it within current CDR algorithms is irrelevant to me. It just makes logical sense... for many of the reasons you listed. We already know by some of the literature posted already in here along with anecdotal experience that RV dysfunction increases mortality. Clot burden has a direct correlation with RV dysfunction. It increases R ventricular wall tension 2/2 increased pulmonary artery pressure leading to RV dilatation, dysfunction and ischemia --> impaired LV filling. I bet you could graph clot burden against pulmonary artery pressure and it would look like a logarithmic curve. It just seems very logical to me. There's alway exceptions...we see those in everything. That's my 2 cents though. To each his own.

Glad you liked the animated gif. I can't believe I didn't get more likes on that one. I was lmao making it.

 

[Jabbed]

I hear ya man. Regarding location of the clot... Personally, I feel clot burden and location is important and regardless of whether someone has done a tremendous amount of research on the issue and/or included it within current CDR algorithms is irrelevant to me. It just makes logical sense... for many of the reasons you listed. We already know by some of the literature posted already in here along with anecdotal experience that RV dysfunction increases mortality. Clot burden has a direct correlation with RV dysfunction. It increases R ventricular wall tension 2/2 increased pulmonary artery pressure leading to RV dilatation, dysfunction and ischemia --> impaired LV filling. I bet you could graph clot burden against pulmonary artery pressure and it would look like a logarithmic curve. It just seems very logical to me. There's alway exceptions...we see those in everything. That's my 2 cents though. To each his own.

Glad you liked the animated gif. I can't believe I didn't get more likes on that one. I was lmao making it.

By this logic, a bedside ECHO (along with BNP/trop) has significantly more utility in the management of known DVT with suspected PE than a CTA does.

There's no convincing argument for how a CTA would change management aside from making you feel better. At the end of the day though, it's just $$ and probably not that much overall harm in isolation. In the big picture, we spend a lot more on lower utility tests just to make ourselves feel better.

 

[alpinism]

Someday I want to see a study on totally asymptomatic people in v large numbers to find out how many have a small subsegmental PE that never would have come to attention otherwise. It has to happen not infrequently, if my somatic symptom disorder/anxiety/q48h chest pain x years chest pain experiences are representative.

Can almost guarantee you the numbers would be over 1% in the general population and likely even higher in pregnant patients.

 

[GeneralVeers]

Can almost guarantee you the numbers would be over 1% in the general population and likely even higher in pregnant patients.

Considering that catching and disposing of small clots is probably a physiological function of the lungs, we are likely all throwing small PE's frequently, and asymptomatically during our daily lives. The real problem is figuring out which ones represent a pathologic process. Would be interesting for a study to use MRI in the evaluation of healthy people to determine what percentage have physiologic clots, as it would give us better guidance on when to actually treat/admit these.

 

[thegenius]

LOL, I knew it.... Big Ballers! Now I know how you guys walk into every shift:



Which go something like this....

This is still one of the funniest set of images / emotes I've seen. Hilarous! And she's hot!

 

[thegenius]

Well whatdayya know. A colleague of mine diagnosed a PE today. 81 yo man p/w weakness for 4 days, no specific thoracic complaint. Triage vitals, HR 88, RR 30, BP 121/61, 95% RA. CT shows "1. Extensive acute central and peripheral pulmonary artery emboli demonstrating a large saddle embolus as well as a large amount of embolic burden in the distal right and left main pulmonary arteries extending into lobar and segmental branches, more severely involving the lower lungs. 2. Dilated right ventricle indicative of RV strain."

His RR went to 22 while in the ED and admitted. Hemodynamics were pretty darn stable despite what sounds like a clot everywhere in his lungs.

All HIPPA compliant! (I'm surprised he wasn't sicker than he was given these CTs)

 

[maxxor]

Well whatdayya know. A colleague of mine diagnosed a PE today. 81 yo man p/w weakness for 4 days, no specific thoracic complaint. Triage vitals, HR 88, RR 30, BP 121/61, 95% RA. CT shows "1. Extensive acute central and peripheral pulmonary artery emboli demonstrating a large saddle embolus as well as a large amount of embolic burden in the distal right and left main pulmonary arteries extending into lobar and segmental branches, more severely involving the lower lungs. 2. Dilated right ventricle indicative of RV strain."
(I'm surprised he wasn't sicker than he was given these CTs)

Why'd your colleague decide to scan? I wonder if there's a pulmonary infarct or aspiration in the posterior right upper lobe that you are showing us.

 

[thegenius]

Yea good question...the note said something like the family was concerned about his breathing and I think the CXR was negative...so even I think I would scan for a PE if the guy truly had a RR ~30 with clear lungs and a clear XR

 

[GonnaBeADoc2222]

Interesting discussion!

None of us are discharging an unstable PE, I don't think. We are admitting them to the SDU vs ICU for possible targeted therapy.

I really think our current admission practice of stable PEs is all about medmal risk. If tort threat didn't exist, we would be discharging most of these.