Step II question about PE treatment

[dendrites]

When you have a high suspicion (all the classic symptoms) for Pulmonary Embolism, which step comes first?
-Treat with Heparin immediately
- Confirm with Spiral CT
-EKG to R/O MI

I have seen multiple sources say different things. Some say treat ASAP and some say you need to confirm the diagnosis before treating.

Thanks!

 

[StrangerX]

If it was classic you would do the heparin first then spiral CT. EKG would be nonspecific in many cases but would be of more diagnostic value if the patient is in really bad shape (e.g. saddle embolus causing arrythmias or severe vital sign instabilities). But still you would do the heparin first.

Its a tougher call if the patient is non-classic case asking you to differentiate between MI and PE. The question should give you some hints to point you in one direction or the other. As Conrad Fischer says...if they want you to give the answer, they have to tell you something.

 

[ijn]

Hemodynamically stable with symptomatic PE? I'd do the EKG first. Even if you think the guy has a dissecting aortic aneurysm you do the EKG before the CXR. Then you'd get the spiral CT. They aren't going to start therapy with heparin without knowing what the hell is going on with you. How many people have you seen in the ER during your third year who got the CT PE protocol before you even got downstairs? They throw that out like candy.

Now say you're hemodynamically unstable with a contraindication to tPA... they'd probably skip the spiral CT and go straight to the OR for embolectomy?

 

[link2swim06]

Hemodynamically stable with symptomatic PE? I'd do the EKG first. Even if you think the guy has a dissecting aortic aneurysm you do the EKG before the CXR. Then you'd get the spiral CT. They aren't going to start therapy with heparin without knowing what the hell is going on with you. How many people have you seen in the ER during your third year who got the CT PE protocol before you even got downstairs? They throw that out like candy.

Now say you're hemodynamically unstable with a contraindication to tPA... they'd probably skip the spiral CT and go straight to the OR for embolectomy?

Yes they are. Uworld and kaplan disagree with you.

If it is "classic PE" you do heparin BEFORE imaging. I never encountered a question/a text which contradicts that.

This is opposite of a simple DVT. Where you do US first and only if it is positive you give heparin.

Not sure where EKG exists in the algorithm, but the text makes it clear, heparin before CTA.

 

[StrangerX]

Hemodynamically stable with symptomatic PE? I'd do the EKG first. Even if you think the guy has a dissecting aortic aneurysm you do the EKG before the CXR. Then you'd get the spiral CT. They aren't going to start therapy with heparin without knowing what the hell is going on with you. How many people have you seen in the ER during your third year who got the CT PE protocol before you even got downstairs? They throw that out like candy.

Now say you're hemodynamically unstable with a contraindication to tPA... they'd probably skip the spiral CT and go straight to the OR for embolectomy?

UWORLD Question ID: 3859 (Pick CT over EKG/Cardiac Enzymes if classic PE)
UWORLD Question ID: 3717 (If classic PE with sufficient well's score use Heparin)

When I said the EKG would be nonspecific in many cases...I meant in many cases of PE.

You may be right for the real world, but on test I would pick Heparin in classic cases.

 

[dendrites]

thanks everyone!

 

[ijn]

Yes they are. Uworld and kaplan disagree with you.

If it is "classic PE" you do heparin BEFORE imaging. I never encountered a question/a text which contradicts that.

This is opposite of a simple DVT. Where you do US first and only if it is positive you give heparin.

Not sure where EKG exists in the algorithm, but the text makes it clear, heparin before CTA.

Yeah I guess so. What is the Wells' score of a "classic PE"?

The exact guidelines:

5.2.1. In patients with a high clinical suspicion of acute PE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (Grade 2C).

5.2.2. In patients with an intermediate clinical suspicion of acute PE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Grade 2C).

5.2.3. In patients with a low clinical suspicion of acute PE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests provided that test results are expected within 24 h (Grade 2C).

So if your Wells' score is 2 to 6 at hospital where you can get a CT immediately as you are rolled in the door then you'd probably get a CT PE protocol before starting heparin. Suspecting PE as your #1 diagnosis plus clinical signs of a DVT gives you an intermediate risk score of 6. If you follow the guidelines straight then they'd get imaged. If you throw in tachycardia and get to a score of 7.5 you'd start treatment with heparin enroute to the CT scanner.

With respect to UWorld's second PE question, based on the question prompt you could argue he has a score of 6. They give no clinical evidence of DVT (0), he has tachycardia (+1.5), he has a recent history of immobilization (+1.5), and we can probably say PE is the most likely diagnosis (+3). Chest guidelines would say image first? He's in the intermediate, not the high risk category. However yes UWorld's answer is heparin first. I think they need to revise the question and put in something about leg swelling/redness in the physical exam sentence.

 

[evilbooyaa]

I was going to post that knowing Well's score is beyond the scope of Step 2 CK, but they mention it in the explanation. With the first questioin, CT is the obvious first best test if PE is the most likely diagnosis.

With the second question, they also give EKG (sinus tach), CXR (clear lungs), and ABG (resp. alkalosis w/ hypoxia, classic for PE or atelectasis). It's a tough question, especially b/c they have wasted so much time already (EKG, CXR, ABG) but I agree with their answer choice.

I think these are the thoughts that go through your head:
1) Is the most likely diagnosis PE based on the physical exam (pleuritic vs deep chest pain)
2) If so, go w/ Heparin > Spiral CT > anything else.

If the first question had an answer choice of IV heparin, I believe THAT would be the right answer as well.