Pulmonary Embolism: Diagnostic and Management Strategies
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1 ulmonary Embolism: Diagnostic and Management trategies ctober 19, 2018 aratoga prings, NY ver the past ten years, despite thousands of professional articles, new research and new technology, pulmonary embolism continues to be one of the most commonly missed medical diagnosis. The epidemiology of E is difficult to determine because it may remain asymptomatic, or its diagnosis may be an incidental finding; in some cases, the first presentation of E may be sudden death. t is frequently found only during autopsy. ecently, however, we have bent the curve 180 degrees and feel we are over imaging and over treating pulmonary embolism. ulmonary embolism is a common clinical disorder that is associated with high morbidity and mortality, if untreated. t is important to confirm or rule out the diagnosis in patients with clinical suspicion of the disease. ulmonary embolism is both under and over diagnosed, which leads to patients either failing to receive treatment or receiving unnecessary, potentially life-threatening treatment. ational diagnosis and management of suspected E is now possible. A review of diagnostic strategies based on new technology and more sensitive D-dimers reveal a selective approach for optimal efficiency would be an appropriate method of choosing the initial diagnostic test. election should be guided by clinical assessment of the pretest probability of pulmonary embolism and by patient characteristics that may influence test accuracy. oal is to establish an evidence-based thought process utilizing tools in our armamentarium to be selective on what tests we order and when; choosing wisely, selecting the right test for the right patient. ayur V. atel, MD, M, FAC, FACE, FACHE, FACE Chief Medical fficer Access2MD
2
3 Are we getting it right?
4 At what cost?
5 19 year of female student presents after sudden onset of B and C, after using cocaine and marijuana for the first time at a party. n Cs for 2 years. n presentation N noted: H 100/min You noted a H of 70/min Your thoughts?
6 Forty five year old morbidly obese male presented to our clinic for monthly weight check visit which is requirement for pre bariatric surgery. During visit states by the way my left knee is hurting more than usual. Had moved furniture few days prior and thinks just twisted knee awkwardly took wife s naproxen couple times with some relief. Vitals: H at 100/min, 95% on room air Exam: knee is negative, not able to reproduce pain on M or palpation HM: hypothyroidism, chronic joint pain, obesity, Thoughts?...
7 Forty five year old morbidly obese male presented to our clinic for monthly weight check visit which is requirement for pre bariatric surgery. During visit states by the way my left knee is hurting more than usual. Had moved furniture few days prior and thinks just twisted knee awkwardly took wife s naproxen couple times with some relief. Vitals: H at 100/min (usually 80), 95% on room air Exam: knee is negative, not able to reproduce pain on M or palpation HM: hypothyroidism, chronic joint pain, obesity, Thoughts?...
8 Your Thought rocess
9 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule Low isk Very Low isk THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) afe to discharge home
10 High isk Moderate isk NE: reec Trusting your alternative diagnosis Low isk Very Low isk
11 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis TW: EC rule Age < 50 ulse < 100 p2 > 94% No unilateral leg swelling No hemoptysis No recent surgery No history of E or DVT No hormone use
12 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria Low isk Very Low isk
13 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria Clinical feature oints Low isk Very Low isk Clinical symptoms of DVT 3 ther diagnosis less likely than E 3 Heart rate greater than 100 beats per minute mmobilization or surgery within past 4 weeks revious DVT or E 1.5 Hemoptysis 1 Malignancy 1 Total points < 4 points get a D-dimer > 4 go to imaging
14 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis When to order a D-dimer? TW: EC ule THEE: Wells Criteria A. EC negative B. Low probability per Well s criteria. C. Moderate probability per Well s criteria D. High probability per Well s criteria F: D-dimer Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
15 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria When to order a D-dimer? Wells E core F: D-dimer Low isk Very Low isk - DD 0.5% E < 4 + DD 23% E - DD 16% E >4 +DD 60% E Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
16 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria When to order a D-dimer? Wells E core F: D-dimer Low isk Very Low isk < 4 rder D-dimer >4 o to CT Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
17 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) 1. ingle detector Helical CT 2. Multi ection piral CT (64 slice) 3. CT ulmonary Angiogram (arterial imaging). 4. Chest CT with contrast (venous imaging) 5. High resolution CT
18
19 19 year of female student presents after sudden onset of B and C, after using cocaine and marijuana for the first time at a party. n Cs for 2 years. H 100, now 70
20 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule Low isk Very Low isk THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) afe to discharge home
21 High isk Moderate isk NE: reec Trusting your alternative diagnosis 19 year of female student presents after sudden onset of B and C, after using cocaine and marijuana for the first time at a party. n Cs for 2 years. H 100, now 70 Low isk Very Low isk
22 High isk Moderate isk NE: reec Trusting your alternative diagnosis 19 year of female student presents after sudden onset of B and C, after using cocaine and marijuana for the first time at a party. n Cs for 2 years. H 100, now 70 Low isk Very Low isk Not necessary or good practice to Apply EC rule order D-dimer rder a CT
23 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis 35 year old woman complaints of pleuritic Chest pain and intermittent B MH: Negative n C 120/78, 100/min, 20/min, Afebrile, 2% 95% Exam: edema on left ankle??
24 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis TW: EC rule Age < 50 ulse < 100 p2 > 94% No unilateral leg swelling No hemoptysis No recent surgery No history of E or DVT No hormone use
25 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria Clinical feature oints Low isk Very Low isk Clinical symptoms of DVT 3 ther diagnosis less likely than E 3 Heart rate greater than 100 beats per minute mmobilization or surgery within past 4 weeks revious DVT or E 1.5 Hemoptysis 1 Malignancy 1 Total points < 4 points get a D-dimer > 4 go to imaging
26 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria When to order a D-dimer? Wells E core F: D-dimer Low isk Very Low isk < 4 rder D dimer >4 o to CT Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
27 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) Low isk Very Low isk
28 Forty five year old morbidly obese male presented to our clinic for monthly weight check visit which is requirement for pre bariatric surgery. During visit states by the way my left knee is hurting more than usual. Had moved furniture few days prior and thinks just twisted knee awkwardly took wife s naproxen couple times with some relief. Vitals: H at 100/min, 95% on room air Exam: knee is negative, not able to reproduce pain on M or palpation HM: hypothyroidism, chronic joint pain, obesity, Thoughts?...
29 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule Low isk Very Low isk THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) afe to discharge home
30 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis Forty five year old morbidly obese male presented to our clinic for monthly weight check visit which is requirement for pre bariatric surgery. During visit states by the way my left knee is hurting more than usual. Had moved furniture few days prior and thinks just twisted knee awkwardly Vitals: H at 100/min (usually 80), 95% on room air Exam: knee is negative, not able to reproduce pain on M or palpation
31 High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis TW: EC rule Age < 50 ulse < 100 p2 > 94% No unilateral leg swelling No hemoptysis No recent surgery No history of E or DVT No hormone use
32 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria Clinical feature oints Low isk Very Low isk Clinical symptoms of DVT 3 ther diagnosis less likely than E 3 Heart rate greater than 100 beats per minute mmobilization or surgery within past 4 weeks revious DVT or E 1.5 Hemoptysis 1 Malignancy 1 Total points < 4 points get a D-dimer > 4 go to imaging
33 High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria When to order a D-dimer? Wells E core F: D-dimer Low isk Very Low isk < 4 rder D dimer >4 o to CT Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
34 lan: Continue naproxen N Follow up in one week if not better Three days later (aturday), develops sudden onset of chest pain and B, Went to E Diagnosis: E DVT (Left popliteal) Thoughts?..
35 cenario A 31 year old African-American female complains of total body pain for 4 days due to a painful sickle cell crisis. he also reports dyspnea for the last 4 days. Her vital signs include a pulse of 126, respiratory rate of 24, blood pressure of 134/74, and oxygen saturation while on room air of 92%. he is afebrile. he smokes 1 pack of cigarettes per day and drinks a moderate amount of alcohol. The remainder of her physical examination is normal
36 i s k High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule ro u p Low isk Very Low isk THEE: Wells Criteria F: D-dimer FVE: CT pulmonary angiogram (CT venogram) afe to discharge home
37 i s k ro u p High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis A 31 year old African-American female complains of total body pain for 4 days due to a painful sickle cell crisis. he also reports dyspnea for the last 4 days. Her vital signs include a pulse of 126, respiratory rate of 24, blood pressure of 134/74, and oxygen saturation while on room air of 92%. he is afebrile. he smokes 1 pack of cigarettes per day and drinks a moderate amount of alcohol. The remainder of her physical examination is normal
38 i s k ro u p High isk Moderate isk Low isk Very Low isk NE: reec Trusting your alternative diagnosis TW: EC rule Age < 50 ulse < 100 p2 > 94% No unilateral leg swelling No hemoptysis No recent surgery No history of E or DVT No hormone use
39 i s k High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria Clinical feature oints ro u p Low isk Very Low isk Clinical symptoms of DVT 3 ther diagnosis less likely than E 3 Heart rate greater than 100 beats per minute mmobilization or surgery within past 4 weeks revious DVT or E 1.5 Hemoptysis 1 Malignancy 1 Total points < 4 points get a D-dimer > 4 go to imaging
40 i s k High isk Moderate isk NE: reec Trusting your alternative diagnosis TW: EC ule THEE: Wells Criteria F: D-dimer Wells E core ro u p Low isk Very Low isk < 4 rder D-dimer >4 o to CT Christoper, JAMA 2006 Wells, et al, Thromb Haemost, 2000 VDA and Tinaquant D-dimer assays
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