If you care about pulmonary embolism (PE) and you are not following @klinelab, then you are missing out.
Here are some of the things I have learned so far:
Diagnosis
- Causes of False Negative D-Dimer: Symptoms>72 hrs, distal clots, lipemia with turbidimetric assays, and blocking proteins
- Sudden onset of dyspnea or chest pain has zero predictive value for or against PE (Ann Emerg Med 2010;55:307)
- Two point DVT may not be enough due to missed SFV Clots (J Thromb Thromb 2014;37(3):298)
- Age <65, witnessed arrest and PEA as initial rhythm predicts >50% probability of PE as the cause of arrest in a small study (see Mike's comments below) (PMID 15797276)
Evaluation of PE Patients
- Thrombophilia testing is a waste of time (PMID 23235639)
- The Daniel EKG Score can rule-in Severe Pulmonary Artery Hypertension (Chest 2001;120(2):474)
- He uses Hestia to determine acceptably low risk for Out-Pt treatment, but not ones with pulmonary infarction (they bounce back secondary to pain)
- A study shows high rates of Chronic ThromboEmbolic Pulmonary Hypertension in higher-risk PEs (Thromb Res 2011;127(4):303)
Treatment
- Patients with metabolic syndrome may have resistance to fibrinolysis with tPA
MedMal
- Any new onset hypoxemia must be explained clinically and in the chart
- Must also explain signs of acute pulmonary hypertension on ecg (PMID 19766353)
- Bronchitis doesn't cause SOB unless there is bronchospasm
Scott Weingart
An ED Intensivist from NY.
ah…see…Twitter aint that piffy 🙂
Scott, Scott, Scott, Where did your mother and I go wrong? Really? The old >65 and witnessed arrest =->50% had PE? Read this study in about 2009, it was crap then, and it is now recycled crap. Don’t have the full study in front of me, but even from the abstract it is clear that this is one of those “If I publish something, I can get more funding” studies. Don’t get me wrong, I like Dr. Kline’s work, I think he’s done amazing things for PE in Emergency Medicine. This article isn’t one of them. Where to start? Well lets start with n. N=44. N=44 means that it is a remarkable small study. 44 subjects enrolled, 18 had PE. that’s 40%. Oh wait, only 33/44 actually had the imaging or autopsy to say a PE was present. Hmmmmmm selection bias anyone? Oh, and autopsy as gold standard? Thought we’d been through this myth before. Ok so the best we can say is that 18/44 patients presenting with PEA had PE. Was this causative? We have no idea. So the best we can say is that age<65, witnessed arrest, and PE = PRESENCE OF PE by questionable standard 40% of… Read more »
Mike, I will add a comment in the post directing people to your comment. I think you are not giving this study its proper due though. Yes it is small, but all of these single-center arrest studies will be. This was not their first time, this was a validation of a prior derivation set. It was not autopsy showed an incidental clot, it was that the ME unequivocally stated it was the cause of death in both studies. Or they found radiographic evidence of clot. The only 1 that is sketchy is when they used echo finds of massive RV as evidence, I think that was 1 or 2 of their patients. Even if you eliminate those, it was still ~50%. The number was not 44, it was 33 patients who had a clear deliniation of cause of death. There was PE in 18 of them (or even 16/33 if you want to quibble with the echo pts). This is by no means high-level evidence, but I think calling it mythical is not using it for what its worth.
Mike, you have an odd way of showing deep respect!
I dont see what is wrong with Scott’s posting and its wording
He is highlighting some published literature not saying it is factual truth but something to be considered and appraised.
And he is entitled to expressing his own opinion!
Thanks Minh for always defending me, but Mike has been one of my best peer reviewers since the beginning. Mike–keep on doing what you are doing. You always keep me in line or make me think. You should have no fear about continuing to do so just as you always have.
Minh and Scott,
I hope that my rant will be taken in this context:
This is #FOAMed, the great advantage that we all spout is that of immediate, post-publication review and discussion.
While my approach could have been different (Scott, you were certainly kinder when you reviewed my book chapter!), part of my approach is to trigger discussion, investigation and further the #FOAMed ethos.
If I offended, I apologize.
Mike
see above
Scott, you skipped the best one!
“I think owning a dog reduces risk of venous thromboembolism among otherwise high-risk patients. I’m going to figure out how to test that.”
yeah, i was waiting of the evidence for that one