Low risk PE dc from ED

[Apollyon]

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Early adopter?? The rest of the world manages PE this way. Same with low risk chest pain. And atrial fib (in the sense that they get discharged and not admitted). But as was previously suggested, management plans that are well supported by the literature and supported by guidelines might not work in the med mal environment of the US

I don't know, honestly - do they have DOACs for the 4 billion+ poor people in the world?

 

[gro2001]

Early adopter?? The rest of the world manages PE this way. Same with low risk chest pain. And atrial fib (in the sense that they get discharged and not admitted). But as was previously suggested, management plans that are well supported by the literature and supported by guidelines might not work in the med mal environment of the US

I wouln't jump as far as to say that the rest of the world manages PEs the way you describe they are managed in Canada. I know of a couple of places outside the US that manage it more or less the "American" way (ie: admit most PEs for anticoagulation). I currently practice at one of those places.

Also, is there any literature to suggest that the practice you describe is really uniform in Canada? People often have this impression that their practice is more universal than it actually is. I am not saying this is the case with you, but this is definitely a phenomenon I've observed, so I am just wondering if there is any specific scholarship to back up the homogeneity of Canadian practice that your posts imply.

 

[deleted859535]

Welcome to America, where the med.mal system is not about good or bad medicine - its about good or bad outcomes and the hot potato. I thought you guys up there just prescribed "don't eat the yellow snow" for your PEs, anyways. (I kid, I kid).

Classmate of mine from residency had this case in his first year out: 30-something female with chest pain and an already diagnosed PE. She's on warfarin already, but comes in because "the pain is worse". What is he to do; re-scan her? No. Start another drug? No. (This was before DOACs were a thing). Supportive care and discharge, which is what any doc with good sense would do.

Gal is dead several days later from.... more PEs.

First year out. First lawsuit.

Settled.

I don't kid.

Just curious -- what state was this?

 

[RustedFox]

Just curious -- what state was this?

Great Lakes region; lets keep it at that.

 

[Rendar5]

You guys are nuts. Put them on a DOAC, discharge them, and call it a day. At worst, if our patients can't afford a DOAC, I'll put them on LMWH, start Warfarin, bring them back in the next few days till their Warfarin is therapeutic, and D/C them to their GP for followup care. I've never heard of a patient in the EDs where I work, coming back in arrest as a result of this. To admit a stable patient with PE who doesn't require O2 or have submassive/massive PE is silly.

One year ago my partner had a patient who was diagnosed with a DVT at another ED and was placed on Xarelto and given the first dose. They came to our ED in cardiac arrest six hours later after they were discharged. I don’t know if the details to know if I would’ve just heard the patient to, although I do normally discharge patients with the returns are out of it for their doctor provided that there is no hints of a PE. It’s nice to think that medicine is cut and dry, but it isn’t. These medicines reduce expansion of the clot, they do not dissolve the clots. The clots are still there short of giving TPA or a thrombectomy.
There is a reason that there is still a mortality rate for people with PE on DOAC’s. We are providing patients a treatment, not a cure.

 

[n2b8me]

Kaiser is using a risk stratification tool to for this.


RISK STRATIFICATION TOOL FOR PULMONARY EMBOLISM (PE)

ELIGIBILITY CRITERIA

Patient is an adult (≥18 years), with an episode of acute PE.

Patient was diagnosed by imaging today in the ED or in the past 12 hours.

Patient had NOT been previously diagnosed with DVT or PE in the last 30 days.

Patient is NOT pregnant.

Patient will receive full PE treatment, NOT comfort care only.


DOES THIS PATIENT QUALIFY?

Yes, Continue >

PULMONARY EMBOLISM SEVERITY INDEX (PESI)

Altered Mental Status

Male

Cancer

Heart Failure

Chronic Lung Disease

Age

Temperature <36° C

Respiratory Rate ≥30/min

Heart Rate ≥110/min

Systolic BP <100 mmHg

O2 Saturation <90%

PESI Score PESI Class All-cause Mortality 7d 30d

≤64 I 0% 0% Outpatient management is often appropriate

65-85 II < 1% < 1% Outpatient management is often appropriate

86-105 III < 1% 3% Outpatient management may be possible

106-125 IV < 1% 5% Outpatient management may be possible

≥126 V 5% 13% Inpatient care is often indicated


CONSIDER REASONS TO HOSPITALIZE

PE FACTORS (pre)syncope, elevated troponin/BNP, RV strain on CT/echo, saddle PE or extensive DVT clot burden, hypotension, hypoxemia, elevated INR, has or needs IVC filter or thrombolytics, needs IV opioids, anticoagulant intolerance

COMORBIDITIES recent major surgery/bleed/stroke, severe renal dysfunction, active bleeding, low platelet count, history of intracranial hemorrhage, extreme frailty

BARRIERS TO ADHERENCE social (lack of phone/support/transport), EtOH/drugs, dementia/psych, patient/family preference for inpt care

OTHER



Thromb Res. 2016 Dec;148:1-8. doi: 10.1016/j.thromres.2016.09.023. Epub 2016 Sep 24.
Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?

 

[Old_Mil]

But as was previously suggested, management plans that are well supported by the literature and supported by guidelines might not work in the med mal environment of the US

This is the real issue. Stable Canadian PEs go home on NOACs. The knowledge that you can go in to work and not have to practice defensive medicine is great.