P.e.

[yalemd]

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Once suspected clinically, what is the next best step in the mangement and why; ABG or O2 and Hep? I would say O2 and Hep. cause it is emergency case and you don't have time for ABG; the thrombus may propagate or pul.infarction may occure.

Thanks

 

[Golding]

Once suspected clinically, what is the next best step in the mangement and why; ABG or O2 and Hep? I would say O2 and Hep. cause it is emergency case and you don't have time for ABG; the thrombus may propagate or pul.infarction may occure.

Thanks

Unlike Pericardial Tamponade in the other thread, PE is not a purely clinical diagnosis. You need to do a few things to prove it first. Arterial Blood Gas, EKG, and Chest X-Ray are usually the things you'll start off with to prove. Most of the time, those aren't even options because it's assumed they're done. I recall only one QBook that made this point.

After that, then yeah you'll give Heparin if you still suspect PE.
Rule out with D-Dimer.
If the patient had neurosurgery or has other contraindications to Heparin, do an IVC Filter.
If the patient is unstable, use fibrinolysis.

PE has a pretty extensive algorithm that's worth going through, because they can ask a lot of varied questions about it that can fool you... even if you think you have it down solid. It's not always quite as simple as Suspect PE -> Give Heparin + O2

 

[OveractiveBrain]

Ay.

Dyspnea deserves a CXR, ABG, and EKG to rule out everything EXCEPT the PE. Those are done first in real life, but for a test, they are NEVER the right answer because none of them are sufficiently sensitive or specific. EKG may show S1Q3T3, ABG shows hypocapnic hypoxia, CXR may show wedge infarct or clear.

Pulmonary Embolism is diagnosed based on the following

(1) If no inflammatory disorder and you think PE is very unlikely (well's criteria < 2) get a D-Dimer to rule out. IF SUSPECTED NEVER GET A D-DIMER

(2) CT scan is the BEST test for PE. Angiogram is dangerous, with greater risk, and equally as effacious.

(3) If a patient cannot get a CT scan with contrast you get a V/Q scan

If the question says "Tachycardia, Dyspnea, Clear CXR, normal EKG, and Hypoxic Hypocapnia" get a CT scan

If the question says "shortness of breath with tender calves" get a CXR.

Treatment is reserved only after the diagnosis is made. Step-Up, First Aid, and Mass Gen Book all have algorithms for you to look at. Obviously, if the patient is "short of breath" they should go on oxygen right away. Heparin is reserved after the CT scan confirms the diagnosis. Unless there is a massive saddle embolus (in which case fibrinolysis), the patient is NOT going to die from a PE in minutes, they die in hours, so you have time to play.

The treatment for a PE, even if already on coumadin with an INR of 5, is heparin. Add the IVC filter for chronic management, after you've protected this admission with heparin