Unnecessary Tests

[southerndoc]

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So, I get a consult in the ED. A woman with cervical cancer who is getting chemo. She's in the ED not because she's weak, having pain, etc., but because of vaginal bleeding.

I notice on the chart that the ED doc has given her an inch of nitro paste, done a stat 12-lead, and ordered a full cardiac workup (including troponin, CK-MB, etc.). He mentions nothing of this when giving me a report before I see the woman.

When I ask the patient about chest pain, shortness of breath, fatigue, dizziness, and all that good stuff, all she can report is fatigue, which has not changed from the fatigue she's had for the past month. She denies any symptomatology except her vaginal bleeding.

This woman is on Coumadin and had an INR of 7. It's unlikely that she's clotted off, and she certainly isn't having any symptoms to suggest an MI.

Am I missing something here? No offense, but what's up with the tests and nitro here?

 

[deleted6669]

sounds like overkill...most em docs/pa's I know would not do this.
maybe he was thinking of a PE. she has a few risk factors, but I agree, on coumadin this is fairly unlikely. what was the indication for coumadin to an INR of 7? was she taking too much? was the chemo interacting with her warfarin? sounds weird...

 

[pinbor1]

I don't know what her cardiac risk stratifications are but this may be the reasoning behind the tests.

I think he was worried about myocardial ischemia secondary to anemia. With the acute blood loss, the physician may have been worried that she was going into high output heart failure. What I think may have been concerning was the fatigue which can be the single presentation in atypical MI's, though it doesn't sound like it given the length of her fatigue symptons. The chemo may very likely be the cause of the fatigue, but it can also be of cardiac concern if she is on anything known to cause cardiomyopathies.

P.S. I'm sure a big portion of this was also CYA Medicine

Just my opinion and I'm no expert.

 

[southerndoc]

Originally posted by emedpa
maybe he was thinking of a PE. she has a few risk factors, but I agree, on coumadin this is fairly unlikely. what was the indication for coumadin to an INR of 7? was she taking too much? was the chemo interacting with her warfarin? sounds weird...

Actually the woman did have a history of DVT's and a PE, but she had a Greenfield filter in place. Her Coumadin dose was recently bumped up. Evidently it was bumped too high.

Please explain how troponin, CK-MB, and nitro paste are beneficial in acute pulmonary emboli. I've never heard that before... but this is a learning process. 🙂

 

[deleted6669]

I was actualy referring to the ekg. there is a pattern(s1q3t3) seen on ekg with some pts with PE.
the cardiac enzymes and nitro paste sound like cardiac workup overkill.

 

[southerndoc]

Originally posted by emedpa
I was actualy referring to the ekg. there is a pattern(s1q3t3) seen on ekg with some pts with PE.
the cardiac enzymes and nitro paste sound like cardiac workup overkill.

Yea, I knew about the EKG findings (along with d-dimer, which would be useless in this patient because of her vaginal bleeding, and spiral CT's, V/Q, etc.).

Maybe nitro and tropinins are the new ED workup for VB?

 

[afmsboy]

aah! That infamous EKG finding of PE. I recall reading somewhere this is one of the rarest findings in PE and is seen in less than 5-10% of PEs (NMS review for Step2). However it seems to be a favorite question for examiners and PIMPsters.

😕 😕 😕

 

[Annette]

I think Pinbor is on the right track- ischemia secondary to anemia, cardiotoxic meds. It does sound like CYA, but maybe the doc had been burned before.

 

[jashanley]

First of all there is no indication for an INR of 7, ever. Her INR was elevated likely due to poor follow up or medication interactions, is she on amiodarone? She could have vit k deficiency or malabsorption, liver failure is also a possibility but all are highly unlikely.
Second it is possible to get a PE post greenfield filter placement and on therapeutic coumadin (an indication for filter placement is recurrent PE on therapeutic coumadin). Filters are only effective for a few months.

Secondly, nitropaste is not indicated unless the patient is having continued chest pain.

An EKG is always useful in these patients. Although I wouldn't reach for that with her initial complaint of vag bleeding.

I can see getting a set of enzymes in an old woman with fatigue. MI can present atypically in the elderly. But it is of low likelihood, especially if she presented with a c/o vaginal bleeding.
She is most likely very anemic as she has good reason to be so.

 

[blackcat]

even in an old woman with fatigue what is ONE set of normal enzymes going to tell you?? is her chance of an AMI 0%?
not likely.

 

[pinbor1]

jashanley,

Quick verification, regardless of a positive EKGs, troponins or CKMBs, would you basically treat her by optimizing her fluid status (i.e. transfusion) and ?beta blockers since any ischemia is likely secondary to her anemia c high output heart failure. Do we know what her hgb/hct was. Also, isn't nitropaste probably a bad idea given the fact that she is probably hypovolemic.

And Annette, thanks for the validation

 

[jashanley]

One set of enzymes can tell you a lot. However, it all depends on how far out from an event you believe her to be. If she has had fatigue for a few days....then a single negative troponin would tell me a lot. if she woke up this AM wiped out, and shows up in the ED two hours later then a single set won't help one bit but a set of two might.
I might avoid a beta blocker in this lady to start. It certainly shouldn't be started in the ED, unless you truly believe her to be having an ischemic event. It all depends on her vitals. I certainly would optimize her fluids and I would start a transfusion when she got to the floor (assuming her hgb is very low). I would also be more apt to transfuse her due to her symptoms. I usually feel comfortable holding transfusions till people reach a hgb of 8 if they are asymptomatic. Transfusions aren't without their shortterm and longterm risks.
Again, without chestpain nitropaste probably should not be used. It certainly can put her BP in the toilet being that she is preload dependent. I use nitropaste for patients with continued chestpain in the ED or on the floor, in combination with morphine doses. The goal would be pain relief.

Who here believes she had or is having an ischemic event? Just a quick poll.

 

[southerndoc]

Originally posted by jashanley
First of all there is no indication for an INR of 7, ever. Her INR was elevated likely due to poor follow up or medication interactions, is she on amiodarone?

She is not on amiodarone. Her coumadin dose was recently bumped up less than 3 weeks prior to presentation to the ED. How often do you guys follow up on coumadin dose adjustments? At any rate, her internist was handling this. We did advise her to go back to her previous dose (which she still had pills left) and to schedule an appointment with her internist ASAP.

The woman has had a poor intake of nutrition. Vitamin K deficiency would not surprise me.

Regarding the comment of when the patient hits the floor, this patient was not admitted. It was felt that her vaginal bleeding was actually not a significant change in her usual amount of vaginal bleeding. She had terminal cancer. Her chemo and radiation treatments were discontinued, and an arrangement was being made at the time for hospice.

 

[Coleman]

To respond to your question, I do not think she has had an ischemic event, but that does not mean that I would not work her up for one. Let's say this is purely in the best interest of the pt, and not CYA medicine, with her history of vaginal bleeding (unknown amount and duration from the hisory and possible anemia-related ischemia), fatigue history, chemo with its potential cardiotoxicity, and age and PMH not given (post-menopausal? uncontrolled diabetes?).

Also, one enzyme level if you are concerned about acute ischemia is not helpful. But if she was admitted early with the "assumption" that the internist would follow-up with serial enzymes, that would be different.