Pulmonary embolism

[berdugo75]

I've found several conflicting answers for the initial treatment of PE.

In one source it says: 1) CXR, ECG, ABG, 2) V/Q Scan, 3) Heparin

Another source says: 1) CXR, ECG, ABG, 2) V/Q Scan, 3) Fibrinolytics

And a third one says: 1) CXR, ECG, ABG (NEGATIVE), 2) Treat with Heparin.

So what the heck is the correct answer?

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[rahulb]

if their vitals are unstable and the clinical suspicion for PE is high, start heparin immediately and confirm with CT or V/Q

if they're stable and labs are equivocal i guess the heparin can wait

i guess #3 is what i would choose

 

[Golding]

PE questions are a pain because of this sort of thing. It seems that #1 and #3 are interchangeable depending on the stability of the patient, but #3 is probably safest and best way to go. Thrombolytics are only used if the patient is hemodynamically unstable (hypotension, RHF, etc). But the CXR, ECG, and ABG are definitely done first to document that there is reasonable suspicion for PE.

 

[yalemd]

PE once suspected first start O2 and Hep. Then CT angio if creat is high go V/Q scan.

If unstable like; massive PE, Sx of RVF (cor pulmonal) or hemodynamically unstable, go thrombolytics or open empolectomy.

That's what I read in kaplan and saw on UW.

 

[yalemd]

I've found several conflicting answers for the initial treatment of PE.

In one source it says: 1) CXR, ECG, ABG, 2) V/Q Scan, 3) Heparin

Another source says: 1) CXR, ECG, ABG, 2) V/Q Scan, 3) Fibrinolytics

And a third one says: 1) CXR, ECG, ABG (NEGATIVE), 2) Treat with Heparin.

So what the heck is the correct answer?

Seems like all agree on #1 (CXR, EKG, ABG) so, I would say more probable answer is number 3, cuase you can't wait for V/Q san and not to give hep. We should give hep to prevent extention of the clot.

 

[OveractiveBrain]

The general algorythm is:
CXR, EKG, ABG --> CT Scan --> Heparin
Basic Stuff --> Diagnosis --> Treatment

Vignette is screaming PE? (1) CXR (clear), EKG (S1Q3T3 soft sign), ABG (hypoxic respiratory alkalosis soft sign), do a CT Scan unless contraindicated. Once diagnosed, start heparin and bridge to warfarin x 6 months.

But there are many permutations of the process

Patient is in RENAL FAILURE or has CONTRAST ALLERGY? V/Q scan instead of CT scan. V/Q scan is divided into High Risk (give Heparin), Low Risk (do nothing), and Moderate Risk (consider CT or Angio anyway).

Patient is ALREADY on warfarin? Add IVC filter but continue warfarin.

Patient is CRAPPING OUT from Right Heart Failure and Saddle Embolus confirmed? Fibrinolytics or Embolectomy

Vignette says probably nothing? Start with a D-Dimer.

Patient has symptoms of DVT but no pulmonary symptoms? Start with U/S