PE and Thee.

[gman33]

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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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Vs changes can be a late finding in large pe.
The pe could be causing right heart strain with normal or close to normal vitals.

You could get an echo and forgo the ct, but there probably has to be a good reason for not getting a ct, other than radiation.

Also making the definitive diagnosis of pe may change the long term anticoagulation plan.

The short answer is that i usually get a ct unless there is a contraindication.

If I think there is a dvt and a pe, I usually pursue the pe diagnosis first.

 

[bravotwozero]

Vs changes can be a late finding in large pe.
The pe could be causing right heart strain with normal or close to normal vitals.

You could get an echo and forgo the ct, but there probably has to be a good reason for not getting a ct, other than radiation.

Also making the definitive diagnosis of pe may change the long term anticoagulation plan.

The short answer is that i usually get a ct unless there is a contraindication.

If I think there is a dvt and a pe, I usually pursue the pe diagnosis first.

Let's say we reverse the situation. Positive PE on CTA, and clinically looks like a DVT. Would you bother with a venous Doppler to confirm dvt?


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[deleted547339]

Let's say we reverse the situation. Positive PE on CTA, and clinically looks like a DVT. Would you bother with a venous Doppler to confirm dvt?


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No.

 

[RustedFox]

I had two PEs in adjacent rooms a few shifts ago.

First guy was the tricky one. In town from the northeast for a sports tournament, right sided flank/back pain of a nagging nature with fever. Seen by MLP at our sister hospital the day prior. HR = 140, Temp = 39 (at time of prior visit). MLP shoots chest x-ray, calls it pneumonia (nevermind the radiology read of "no disease, clear fields"), gives the guy Levaquin and boots him out the door. That's all the workup that was done. I could have slapped that MLP. I see him next day. Normal vitals, normal sat... "just not getting better". Boom: RLL PE, big one.

Second (gal) was sad. Stage-IV breast ca with bone mets. She was quick to attribute the chest pain to noncompliance with her acid reflux meds. LLL PE, big one.

 

[TheBlueBlazer]

If they have symptoms consistent with a PE, and a known DVT, with normal vitals, I would do a echo, trop, BNP and if those were normal, I'd anticoagulate with a NOAC and refer as outpt to PCP/pulm/heme depending on who normally catches these downstream at your place and probably give a quick call to them to try and facilitate. No CT, no admission, just good dc instructions. No need for unnecessary costs, radiation or admit to end up in the same place.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447174/

 

[WilcoWorld]

If they have symptoms consistent with a PE, and a known DVT, with normal vitals, I would do a echo, trop, BNP and if those were normal, I'd anticoagulate with a NOAC and refer as outpt to PCP/pulm/heme depending on who normally catches these downstream at your place and probably give a quick call to them to try and facilitate. No CT, no admission, just good dc instructions. No need for unnecessary costs, radiation or admit to end up in the same place.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447174/

I'd like a hospital policy on outpatient PE management to be in place before I start discharging PE's. I'm not saying it's an unreasonable practice, just that this is not an advance that I'm eager to be on the cutting edge of.

 

[TheBlueBlazer]

not absurd. If I remember correctly, ACEP was looking at updating the practice guidelines, and the American College of Chest Physicians includes the possibility of outpatient management in their guidelines. I think that having someone enthusiastic about the idea who is willing to play catch when you discharge them is important.

 

[gutonc]

not absurd. If I remember correctly, ACEP was looking at updating the practice guidelines, and the American College of Chest Physicians includes the possibility of outpatient management in their guidelines. I think that having someone enthusiastic about the idea who is willing to play catch when you discharge them is important.

I love picking these folks up on the downstream side. It's a legit 10 minute level 5 new patient visit.

Now if I could only get the ED to call me instead of calling upstairs.

 

[leviathan]

I could be wrong but I think there's a study showing 0% 30 day mortality with a negative trop and sPESI score.

 

[RustedFox]

I could be wrong but I think there's a study showing 0% 30 day mortality with a negative trop and sPESI score.

Hey! THIS guy is back ! Where you been, Hobbes?