Ep 113 Pulmonary Embolism Challenges in Diagnosis Part 1

This is EM Cases Episode 113 Pulmonary Embolism Challenges in Diagnosis Part 1. If we were to design a perfect emergency medicine brain buster, it would have all the qualities of pulmonary embolism. It would affect the young and the old. It would be precipitated by seemingly anything: medications, smoking, and even video gaming. It would be dynamic, anything from asymptomatic to killing in minutes. It would have a huge variability in presenting signs and symptoms depending on a whole host of patient factors. It would have multiple decision rules, imaging modalities, and treatment options. It’s as if pulmonary embolism was invented just to challenge the minds of ED docs! In this two part podcast, with the help of thrombosis experts Dr. Kerstin DeWit and Dr. Eddy Lang, we ask the questions that plague us on almost every shift: Which patients require any work-up at all for pulmonary embolism? What’s the utility of PERC and Wells scores? Should the newer YEARS decision tool supplant Wells? When should we order a D-dimer? What is the diagnostic role of CXR, ECG, POCUS, CTA and VQ? How should we work up pregnant patients for pulmonary embolism? How can we use shared decision making strategies for pulmonary embolism to help us do what’s best for our patients, and many more... Podcast production & sound design by Anton Helman, editing by Sucheta Sinha & Anton Helman Written Summary and blog post by Shaun Mehta & Alexander Hart, edited by Anton Helman, August 2018 Cite this podcast as: Helman, A, DeWit, K, Lang, E. Pulmonary Embolism Challenges in Diagnosis Part 1. Emergency Medicine Cases. August, 2018. https://emergencymedicinecases.com/pulmonary-embolism-challenges-diagnosis-part-1/. Accessed [date]. Go to part 2 of this 2-part podcast on pulmonary embolism challenges in diagnosis The diagnosis of PE is a tricky one. It is hardly gratifying when we find an incidental subsegmental filling defect in a 90-year-old patient with multiple comorbidities but missing a larger clot in an otherwise young and healthy patient can be devastating. The problem is, with such a wide variability in presentation and without clear diagnostic directives from the literature, it can be hard to tease apart those who are sick from those who don’t have the disease at all. What we really want are decision aids that maximize diagnostic accuracy while minimizing over-testing and patient harm resulting from over-testing, over-diagnosis and anticoagulant complications.   Pulmonary embolism challenges in diagnosis: What’s all the fuss really about anyways? PEs kill. But not as much as we might think. In the 1990's The Prospective Investigation of Pulmonary Embolism Diagnosis study found a case fatality rate of 15% at 3 months [1], but only 10% of these deaths were directly attributable to PE [2]. Newer data from the EMPEROR Registry in 2011 found that the mortality rate directly attributed to PE was 1%, while the all-cause 30-day mortality rate was 5.4%, and mortality from hemorrhage was 0.2% [3]. Interestingly, most patients who died (85%) succumbed untreated while waiting for diagnostic confirmation. It appears from this data that most patients with PE die of comorbidities which might have placed the patient at risk for PE, such as malignancy or die while waiting for diagnostic confirmation. Much of this decreased mortality may be related to the increase in diagnosis of subsegmental PEs in the past two decades. Comparison of pooled data from uncontrolled outcome studies shows no increase in PE recurrence or death rates for patients diagnosed with isolated subsegmental PEs w...