Learning Objectives Better understanding of diagnosis and management of acute PE Recognize acute PE Learn how to Test Learn how to Treat Take Home Points PE can present as anything Use Wells PERC ID: 644782
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Slide1
Pulmonary Embolism 101
Alex Rankin, MDSlide2
Learning Objectives
Better understanding of diagnosis and management of acute PE
Recognize acute PE
Learn how to Test
Learn how to TreatSlide3
Take Home Points
PE can present as anything
Use Wells +/- PERC +/-
Ddimer
Consider Age Adjusted
Ddimer
Be cautious in your imaging
Be cautious in your treatment Slide4
Definition/ What W
e’ll Cover
PE= obstruction of Pulmonary Artery/branch by embolism originating elsewhere
Emboli
: Air, Fat, Tumor,
Thrombus
Subtypes
:
Acute,
Subacute
(days/weeks), Chronic
Presentation
:
Hemodynamically
Stable
or Unstable
Won’t cover: Pregnancy, Malignancy, VTE prophylaxisSlide5
CasePresentation
Nurse calls 3am Cross Cover
65 y/o female with chest pain
Hospital day #5 for gallstone pancreatitis, slow to progress with diet.
Nonsmoker, no cardiac
hx
, no DM, HTN, no
FMHx
CAD
You astutely list Pulmonary Embolism as possible Differential Diagnosis
Why did you think that?
Now what do you do? Slide6
Clinical Presentation of PE
Anything!
Most Common:
Dyspnea
Pleuritic
Chest Pain
Cough (hemoptysis less common)Slide7
Clinical Presentation of PE
Anything!
- Take away Point #1
Most Common:
Dyspnea
Pleuritic
Chest Pain
Cough (hemoptysis less common)Slide8
Workup of PE
Assess clinical stability
CXR, EKG
Labs:
CBC, BMP, LFTs, INR, ABGSlide9
Classic Imaging Findings
Hamptons Hump
https://
www.uptodate.com
/contents/
image?imageKey
=RADIOL%2F97988&topicKey=PULM%2F8261&source=
outline_link&search
=pulmonary%20embolism&selectedTitle=3~150Slide10
Classic Imaging Findings
Westermark
Sign
https://
www.uptodate.com
/contents/
image?imageKey
=RADIOL%2F98271&topicKey=PULM%2F8261&source=
outline_link&search
=pulmonary%20embolism&selectedTitle=3~150Slide11
Classic EKG Findings
Sinus Tachycardia (most common)
RV Strain (T wave inversions V1-4, inferior leads)
RBBB
RAD
Nonspecific ST/T changes
SI, QIII, TIII
(only 10% of
pts
with PE)Slide12
https://
lifeinthefastlane.com
/
ecg
-library/pulmonary-embolism/Slide13Slide14
How to T
est for PE
Ann Intern Med. 2011 Oct 4;155(7):448-60.
CDS has higher specificity for excluding PE over Clinician Gestalt when used with
DDimer
1. Start with a Clinical Decision Support toolSlide15
Wells Score
https://www.uptodate.com/contents/image?imageKey=PULM%2F54767&topicKey
=
PULM%2F8261&rank=3~150&source=
see_link&search
=pulmonary%20embolismSlide16
Wells Score
Low Probability--Use PERC Score
J
Thromb
Haemost
2008; 6: 772–80.
Low
Prob
+ PERC (-): Sensitivity 97.4%, Specificity 21.9%, False
Neg
rate 1.0%Slide17
Wells Score
Low Probability—Use PERC Score
https://www.uptodate.com/contents/image?topicKey=8261&imageKey
=
PULM%2F94941&source=
outline_link&search
=pulmonary%20embolism
--If ALL negative, no further testing indicated
--If ANY positive, get
Ddimer
Imaging if PositiveSlide18
Wells Score Summary
Low
Prob
(<2)
Use PERC
Intermediate Probability (Wells 2-6)
Get
Ddimer
Imaging if Positive
High Probability (>6)
Proceed straight to imagingSlide19
Wells Score Summary
Take Away #2
Use Wells Score
+/- PERC
+/-
DdimerSlide20
Our Patient
Wells score 4.5
HR >100
1.0
No other
Dx
more likely than PE3.0
Our
pt
:
Moderate Probability
Our
pt
:
DDimer
680
Positive, but is it really positive?Slide21
Age Adjusted Ddimer
JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135
Validated AgeX10 as
Ddimer
cut off for
pts
>50 y/oSlide22
BMJ 2013;346:f2492
doi
: 10.1136/bmj.f2492 (Published 3 May 2013)
Age-adjusted
Ddimer
increases specificity while preserving sensitivitySlide23
Back to our Patient
Ddimer
680
Age: 65
Yes—this is positive
Take Home #3: Consider Age Adjusted
Ddimer
Now what?Slide24
Imaging studies
CT Pulmonary Angiogram
Need good kidneys
Need to be stable for scan
Ventilation/Perfusion Scan
Need clear lungs
Usually not stat study
Bilateral lower extremity duplex ultrasound
Echocardiogram?
Take Away #3: Be cautious in your imagingSlide25
Our Patient
http://
www.stritch.luc.edu
/lumen/
MedEd
/Radio/curriculum/Medicine/PE1.htm
Now what?Slide26
Acute PE Treatment
Generally need admission
PESI Score (30 day Mortality)
Assess Bleeding risk
Rambam
Maimonides Med J. 2014 Oct; 5(4): e0037.Slide27
RIETE Study: Major BleedingSlide28
RIETE Study: Major Bleeding
0 points: 0.3% bleeding risk
1-4 points: 2.6%
>4 points: 7.3%Slide29
RIETE Study: Fatal Bleeding
Nieto, José Antonio et al. Thrombosis Research , Volume 132 , Issue 2 , 175 - 179Slide30
RIETE Study: Fatal BleedingSlide31
RIETE Study: Fatal Bleeding
<1.5 points: 0.10% bleeding risk
1.5-4 points: 0.72%
>4 points: 1.44%Slide32
Acute PE Treatment
Anticoagulation
Heparin
Warfarin
Need to be inpatient for entire bridge
Can stop quickly and reverse effect
Enoxaparin
Warfarin or lifetime
Need to have good kidneys
Direct Oral Anticoagulant?
Need to have insurance
Need to be compliant
IVC filter/
Embolectomy
/
tPA
/
etc
Take Away #4: Be cautious in your treatmentSlide33
Our patient
Improved, Satisfied with her care, discharged home 5 days later. Anticoagulation clinic plans bridge for interval cholecystectomy
Take Home Points
PE can present as anything
Use Wells +/- PERC +/-
Ddimer
Consider Age Adjusted
Ddimer
Be cautious in your imaging
Be cautious in your treatment