Moderator EMEDPA Posted August 6, 2017 Moderator Share Posted August 6, 2017 file under better lucky than good. Guy with zero PE risk factors or sx other than pleuritic chest pain. all stahndard questions negative. any recent long distance travel? no where you from? Kansas. oh, how long have you been here? I just got here today. how did you get here? I drove. how long did it take? 10 hrs that would be "long distance travel". no, I do it all the time. that is a short drive.... D-dimer 10x high nl CTA chest massive PE involving main pulmonary artery....anticoagulated and admitted.... Link to comment Share on other sites More sharing options...
SERENITY NOW Posted August 6, 2017 Share Posted August 6, 2017 Nice! I remember hearing the authors of the PERC audio lecture at some point and they kept saying that their rule has never been wrong... people keep sending them case reports but when the authors dig in there they always find something to disqualify the patient... usually something stupid like the well's criteria of "PE likely number 1 diagnosis"... kind of a cheating trump card when you can always use that one in retrospect haha. Link to comment Share on other sites More sharing options...
PACJD Posted August 6, 2017 Share Posted August 6, 2017 Goes to show you that medicine is more than a scoring questionnaire. Sometimes some investigating and further digging is necessary. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 6, 2017 Share Posted August 6, 2017 Guy was under 50, HR <100, and SpO2>95% on RA?? If so, then yeah, he would've perc'd out. Wells may have caught him though with the "no dx more likely". Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 7, 2017 Author Moderator Share Posted August 7, 2017 I hate wells because of that subjective component. I usually use perc + common sense. I would have thought pleurisy or chest wall strain more likely. I actually gave him toradol before he went to CT as I was basically just satisfying the d-dimer. I expected something like a tumor or other non-pe finding on ct that would explain the d-dimer. Link to comment Share on other sites More sharing options...
sk732 Posted August 7, 2017 Share Posted August 7, 2017 Had an old lady the other day - apparent CHF, only positive was her pacemaker implantation 10 days prior...abrupt SOB, crackly all around, CHF picture on CXR, some improvement with Lasix, but sats not coming up. CT showed pile of PE's on the right. Well's was 1.5. We didn't D-Dimer due to age and recent surgical procedure. What is it they tell us - treat the patient, not the machine or scores right? SK Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 7, 2017 Author Moderator Share Posted August 7, 2017 treat the patient, not their apparent diagnosis... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 7, 2017 Share Posted August 7, 2017 There's a new requirement. Also treat the pt. satisfaction rating. Yes, I'm perturbed at present from a non-compliant patient earlier.Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 7, 2017 Author Moderator Share Posted August 7, 2017 2 hours ago, GetMeOuttaThisMess said: There's a new requirement. Also treat the pt. satisfaction rating. Yes, I'm perturbed at present from a non-compliant patient earlier. Sent from my iPad using Tapatalk I had a pt yell at me because their in-room TV(not a fan) could not get a porn channel in the ER... Link to comment Share on other sites More sharing options...
sk732 Posted August 8, 2017 Share Posted August 8, 2017 7 hours ago, EMEDPA said: I had a pt yell at me because their in-room TV(not a fan) could not get a porn channel in the ER... They're obviously not that unwell at that point...and should be boot phuqued out the door if that's the case. Luckily I don't worry too much about patient satisfaction scores...yet. SK Link to comment Share on other sites More sharing options...
Marinejiujitsu Posted August 8, 2017 Share Posted August 8, 2017 I always use PERC/wells, ling periods if sitting greater than 8 hrs. So, road trips longer than 8 hrs, international flights. Sent from my SAMSUNG-SM-G935A using Tapatalk Link to comment Share on other sites More sharing options...
Guest ERCat Posted August 11, 2017 Share Posted August 11, 2017 I always cover both the Wells Criteria and PERC rule but yeah, sometimes they don't mean jack. I had a 20 year old dude come in with calf pain after he slid down a ladder and scraped the calf along the way. His calf just looked swollen so I ultrasounded him and he had a DVT. At that point I asked about pulmonary symptoms like chest pain, shortness of breath, hemoptysis, racing heart. He said, "Not at all." When I walked out of the room he was like "Well, two weeks ago I had a weird chest pain that lasted a few seconds but that's it." Even though he was 20 I had a feeling I should scan him and he had bilateral PEs! Link to comment Share on other sites More sharing options...
Guest ERCat Posted August 11, 2017 Share Posted August 11, 2017 Also, never forget syncoPE. I have had old people come in ONLY with complaints of syncope and I chest pain or shortness of breath, and totally normal vitals. I have scanned those people if they have VTE risk factors like recent surgery and have caught PEs. Link to comment Share on other sites More sharing options...
kargiver Posted September 1, 2017 Share Posted September 1, 2017 Regardless if PERC and Wells are negative (I'd argue Wells isn't here in this circumstance which negates PERC as a R/O since the pre-test probability according to Wells is ~ 16% and PERC is only useful if pretest probability less than 15% and all criteria are negative) there is always a background noise of the population that develop PEs that will slip through these rules. They are gauged to an approximate 1.6-2% miss rate regardless of what we think as clinicians - its why nothing will ultimately trump gestalt and why the specificity of the D-dimer is important. Strong catch, E, G Link to comment Share on other sites More sharing options...
JMPAC Posted September 1, 2017 Share Posted September 1, 2017 I had a pt yell at me because their in-room TV(not a fan) could not get a porn channel in the ER...What kind of terrible ER doesn't have porn? I hope you at least provided him with some nudie magazines. It's the least you could do. Link to comment Share on other sites More sharing options...
sk732 Posted September 1, 2017 Share Posted September 1, 2017 4 hours ago, JMPAC said: What kind of terrible ER doesn't have porn? I hope you at least provided him with some nudie magazines. It's the least you could do. One of our nurses walked in on a guy that was cranking with his door open the other day...probably shouldn't encourage folks. SK Link to comment Share on other sites More sharing options...
JMPAC Posted September 1, 2017 Share Posted September 1, 2017 One of our nurses walked in on a guy that was cranking with his door open the other day...probably shouldn't encourage folks. SKYikes! We had a homeless woman who kept sneaking into our waiting room to do that in the corner one night. PS - hope you got the sarcasm in my porn comment! Link to comment Share on other sites More sharing options...
Guest JMPA Posted September 3, 2017 Share Posted September 3, 2017 On 9/1/2017 at 6:03 PM, JMPAC said: Yikes! We had a homeless woman who kept sneaking into our waiting room to do that in the corner one night. PS - hope you got the sarcasm in my porn comment! drop the C and you will be like me. on a side note, if PE comes to mind, just test, clinical suspicion is your greatest indication for testing in the real world Link to comment Share on other sites More sharing options...
kargiver Posted November 28, 2017 Share Posted November 28, 2017 Also, remember exactly what the D-dimer is testing... it too can be negative in the presence of a massive PE. The D-dimer tests the breakdown of fibrin to fibrin-degradation product (FDP), and all you are testing is the rate at which that clot is actually being broken down. Like all things in a biological system, it's a stochastic mechanism that operates based on the presence of enzyme(s) necessary to do their jobs, no more. G Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 28, 2017 Author Moderator Share Posted November 28, 2017 11 hours ago, kargiver said: Also, remember exactly what the D-dimer is testing... it too can be negative in the presence of a massive PE. The D-dimer tests the breakdown of fibrin to fibrin-degradation product (FDP), and all you are testing is the rate at which that clot is actually being broken down. Like all things in a biological system, it's a stochastic mechanism that operates based on the presence of enzyme(s) necessary to do their jobs, no more. G YUP, my understanding is that the d-dimer peaks after a week to 10 days and then declines to baseline, even if the clot persists. we had a young pt(40s) with massive b/l PEs and neg d-dimer who was sating 98% on RA, but had persistent tachycardia to 104 or so in our obs unit even while sleeping after passing a treadmill and 2 neg sets of enzymes. an observant doc scanned his chest and found the PEs. Link to comment Share on other sites More sharing options...
narcan Posted December 1, 2017 Share Posted December 1, 2017 On 11/28/2017 at 0:37 PM, EMEDPA said: YUP, my understanding is that the d-dimer peaks after a week to 10 days and then declines to baseline, even if the clot persists. we had a young pt(40s) with massive b/l PEs and neg d-dimer who was sating 98% on RA, but had persistent tachycardia to 104 or so in our obs unit even while sleeping after passing a treadmill and 2 neg sets of enzymes. an observant doc scanned his chest and found the PEs. That's a scary scenario, but a good reminder why tachycardia can never be ignored. Link to comment Share on other sites More sharing options...
bike mike Posted December 3, 2017 Share Posted December 3, 2017 Chest pain = rule out STEMI, aortic aneurysm, and PE. Right thing getting the chest CT! Link to comment Share on other sites More sharing options...
quietmedic Posted March 24, 2018 Share Posted March 24, 2018 My major problem with PERC is the OCP thing. 99% of the young female population in on them, so...does every young female with OCPs and minimal c/p have a PE? Obviously not, but then the PERC score goes out the window. Seems like a fundamental shortcoming of PERC. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 24, 2018 Author Moderator Share Posted March 24, 2018 12 minutes ago, quietmedic said: My major problem with PERC is the OCP thing. 99% of the young female population in on them, so...does every young female with OCPs and minimal c/p have a PE? Obviously not, but then the PERC score goes out the window. Seems like a fundamental shortcoming of PERC. + PERC just gets them a dimer. if neg, you are probably done in the otherwise low risk pt. Link to comment Share on other sites More sharing options...
quietmedic Posted March 24, 2018 Share Posted March 24, 2018 7 hours ago, EMEDPA said: + PERC just gets them a dimer. if neg, you are probably done in the otherwise low risk pt. I know, but when it comes down to it, you aren't going to d-dimer every young female on OCPs with a little tachycardia....maybe it's your regular weekly pt having her usual weekly anxiety attack. My point is that OCPs are so widespread that PERC is immediately useless in almost every female 12-52...and you certainly aren't going to d-dimer every single one of those patients, especially with a much more likely alternative diagnosis (which is a criteria in Wells, but surprisingly not in PERC). Link to comment Share on other sites More sharing options...
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