First time doing this, feeling a little cowboy...

[EMEDPA]

Just had a pt I was fairly sure had a PE(tachycardic, tachypneic, sedentary, pleuritic chest pain, low o2 sat) who I anticoagulated with heparin before getting their CTA results. Fortunately (for me) they did have large b/l PEs. I figured there really was no downside to starting heparin in this pt (they had no hx of bleeding issues) as I could always turn it off. anybody else do this before? I think it was the right call and will probably do so again when faced with a similar acute situation.  

[DogLovingPA]

Nice!   If that was me or my family, I'd be thankful you started the heparin before CT.  Sounds like a good call to me. 

 

No heparin here in UC.  I do have lovenox and I've given it 3 times before obtaining imaging - once for a DVT (I was right) and twice for suspected PE (correct on one, incorrect on the other). 

[EMEDPA]

I thought about lovenox, but chose heparin due to its short duration of action. glad I started it when I did. guy later decompensated a bit and had to get transferred for pulmonary artery intravascular clot retrieval...did ok.

[Deanj59]

I know it's used/validated in managing NSTEMI, but what are your thoughts about using the CRUSADE bleeding risk score for use in this situation?

[EMEDPA]

have not used it before. just ran the #s for the pt above and got "high risk" 10% due to their bp and comorbidities. don't know if that would have swayed me to do anything differently unless that % was significantly higher.

in your experience is this scale better than a few questions about GI bleeding, gingival bleeding when brushing teeth, bruising, etc

[polarbebe]

Have started AC (lovenox or NOACs) for patients to be admitted or discharged for followup the next morning for further workup of possible VTE disease (ultrasound not available and/or vascular lab closed).  Some of the intensivists I work with stress that all PEs should get a loading dose if on a heparin gtt (shortening time to steady state) ... though it rarely is done.   

[PeteK777]

I start hep gtt on all of my patients who I think have a PE ESPECIALLY if they have any evidence of RV strain (if echo done first, elev. troponin or BNP, etc.). The only time I don't anticoag before imaging is for mere CYA PE-rule out

[sk732]

If someone's Wells Score is high enough OR you're just seriously considering it, nobody is going to fault you for starting anticoagualtion for a PE or DVT prior to imaging, especially if there is a wait.  They will, however,  if your charting shows you're highly suspicious and don't do anything though, especially if things go to shyte.  I still usually use dalteparin, just out of habit - unless allergic or have prior bleeding issues, it's unlikely to cause anything worse and it's out of the system latest 24 hours. 

 

$0.02 Cdn

[FriarMedic]

In this same topic- when does a PE need catheter directed Tpa? Had a middle aged gentleman with bilateral extensive PE with saddle embolus , hemodynamically stable and without hypoxia but a bumped trop 0.46 and bnp ~2000 so there is evidence of right heart strain but VSS. There was differing of opinion between hospitalist and IR as to whether emergent tpa was needed for this pt. are there any set guidelines? Who typically makes that call? This pt was not crashing but certainly very high risk.

 

And I waited till I saw the CT , had an attending sign on and started heparin. I think if I started heparin prior to, that would have turned some heads in my shop.

[rev ronin]

And I waited till I saw the CT , had an attending sign on and started heparin. I think if I started heparin prior to, that would have turned some heads in my shop.

Now that you've got a case to discuss, bring it up: "Do you think, given the evidence for anticoag we have in this situation and the clinical picture at the time, that the PA taking care of the patient should have been free to anticoagulate this patient without delaying for attending consultation?"

[FriarMedic]

rev to clarify - The patient was triaged a level 2 and therefore I'm required to have an attending see him prior to disposition. I don't think Head turning would have occurred if I started heparin before talking to an attending, but rather if I started heparin before the CT was done, as emed initially talked about. We all sit right by the PACS viewer so discussion kinda happened all at once when I pulled it up.