I could swear there was an old UWORLD question that had this, but it seems they took it out. If I remember, if there is a pt that has a high pre test probablity of having a PE, then the next step is to give heparin, then do a Spiral CT scan, and if its negative, then discontinue thearpy,if positive, of course continue....can someone shed any light? I saw a question in Rx that said give heparin first before sprial CT, but I dont always trust there explanations....
suspected PE: next best step?
- Thread starter Bagheera
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Sounds right to me. If there's high clinical suspicion (aka high wells criteria pretest probability), heparin should be started ASAP. CTA comes second. If you're given both answer options, definitely pick anticoag in that pt who's SOB, tachy, with previous hx of dvt, etc.
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I remember this question too. If you reset UW it may not show up though in the search until you actually redo the question.
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I don't think they took it out. I had it last week.
But:
PE: heparin first then CT
DVT w/o PE signs: LE US first then if positive heparin
From Kaplan QBook 5th edition, OBGYN Test #2, Q33
43 y/o woman G2P1 at 34 weeks:
-Short of breath since yesterday while lying down
-Pleuritic Chest Pain
-Tachy Pulse (110) w/ sinus tachy on ECG
-Tachypnea (25)
-O2 Sat 93%
-Negative CXR
Question was what is the next best step in management.
The answer is to do a V/Q scan first. The answer claims one must diagnose a PE first before beginning treatment but I feel like the Well's score is HIGH here (at least a 7.5 if one ticks of the first three boxes here: http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/).
Why not give heparin (which was also a choice)? Is it that the patient is relatively stable?
43 y/o woman G2P1 at 34 weeks:
-Short of breath since yesterday while lying down
-Pleuritic Chest Pain
-Tachy Pulse (110) w/ sinus tachy on ECG
-Tachypnea (25)
-O2 Sat 93%
-Negative CXR
Question was what is the next best step in management.
The answer is to do a V/Q scan first. The answer claims one must diagnose a PE first before beginning treatment but I feel like the Well's score is HIGH here (at least a 7.5 if one ticks of the first three boxes here: http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/).
Why not give heparin (which was also a choice)? Is it that the patient is relatively stable?
From Up to Date...
"GENERAL APPROACH Initial management of suspected VTE depends upon the degree of clinical suspicion for acute PE, whether there are contraindications to anticoagulation, and whether PE, DVT, or both are suspected:
When there is a high clinical suspicion for acute PE, empiric anticoagulant therapy is indicated prior to the diagnostic evaluation. Anticoagulant therapy is discontinued if VTE is excluded.
When there is low or moderate clinical suspicion for PE, empiric anticoagulant therapy prior to diagnostic evaluation is determined on a case-by-case basis.
For those patients in whom PE is suspected but anticoagulant therapy is contraindicated, diagnostic evaluation should be expedited. Anticoagulation-independent therapy (eg, inferior vena cava filter) is indicated if VTE is confirmed.
When there is suspicion for DVT alone (no clinical evidence or suspicion of acute PE), anticoagulant therapy is generally withheld until VTE is confirmed, assuming that diagnostic evaluation can be performed in a timely fashion."
If the question didn't present some kind of contraindication then the question is wrong...
Then its either an out of date question based on presumably old info (no idea if that logic reflects old protocols or not) or a bad question that is just incorrect. Wouldn't be the first time I've run across a question that was flat out incorrect in it's rationalization/explanation.
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Not to mention current guidelines don't have you start with a V/Q scan in pregnant ladies regardless.
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Yeah and I don't know why they were dicking around with a CXR. I think if they've already wasted time with other tests they didn't need, then maybe you can confirm your diagnosis prior to treating? Glad I didn't have a question like that ever.
Maybe it's b/c her sat was still acceptable (93%)? And if it was lower then it would be a more significant PE and would warrant anticoagulation faster? Not sure of the answer there.
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To throw another wrench in - remember that a D-dimer can rule out PE (per UTD: "Patients classified as PE unlikely should undergo D-dimer testing with a quant rapid ELISA or a semiquant latex agglut assay. The dx of PE can be excluded if the D-dimer level is <500 ng/mL or negative."
I doubt they'd ask a question getting us to make a clinical judgment call about whether someone has a low enough pre-test probability that we'd feel safe with a D-dimer, but if the question clearly indicates that someone does have a very low pre-test prob, asks something like "what could you do to exclude PE in this patient [who's a 30 yo male/no hospitalization or immobilization/HR <100/no hemoptysis or malignancy or signs of DVT etc]," then I'm going to consider D-dimer.
I doubt they'd ask a question getting us to make a clinical judgment call about whether someone has a low enough pre-test probability that we'd feel safe with a D-dimer, but if the question clearly indicates that someone does have a very low pre-test prob, asks something like "what could you do to exclude PE in this patient [who's a 30 yo male/no hospitalization or immobilization/HR <100/no hemoptysis or malignancy or signs of DVT etc]," then I'm going to consider D-dimer.
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For test purposes, in a pregnant women with signs/symptoms of a PE, what is the best first test?
In general I think testing is similar to a non-pregnant patient and contingent on level of risk. Imaging studies can still be done in pregnant women because the amount of radiation in individual tests is not enough to cause problems for the embryo/fetus. So if medium or high risk, I'd go with Spiral CT first (possibly with angio to confirm). With low risk, I would try to rule out with D Dimers. If they put V/Q scan on the test, I would pick it only if the other options were not available and the risk was high/medium.
V/Q Scan also involves radiation both for the ventilation and perfusion imaging. In either case, I don't think the raditation is enough to harm the fetus as the radiation in an individual radiographic test is not enough (i.e. less than 5 rads). Also you wouldn't be getting a whole body CT, just a spiral chest CT.
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V/Q is a nuclear medicine scan and will involve radiation. Less than a spiral CT, but still present.
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I am pretty sure MTB states that for a pregnant women with signs of PE, the best diagnostic test is a V/Q scan. Not sure if this is correct information, but I think that's what it said in either Pulm or OB...
You are right. Confirmed from UpToDate. They say the choice is controversial but recommend V/Q as it is more accurate and has lower radiation to mom (while higher radiation to fetus/embryo) vs spiral CT.
