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Geneva score for PE


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  • 4 weeks later...

For me, you are either PERC (-) and negative D-dimer or you get worked up for PE if I think you are medium to high risk.  In all the PE literature, the only rule I like is PERC, and adding a dimer is defensible for not CTing someone who is low risk.  

Jeff Kline (the godfather or PE research) is sending home saddle PEs on outpatient therapy now if they meet certain criteria.  No rule has been shown to trump gestalt, and clinical presentation matters most (IMO). I always document why I don't think its a PE in moderate risk folks (always an alternative diagnosis and their dimer is negative) and if high risk by gestalt, they get spun either way.

Just thoughts,

G

 

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1 hour ago, hmmmm3 said:

Has anyone here heard of the YEARS study for PE diagnosis? Probably not enough evidence to start using it, but seems very promising.

https://www.ncbi.nlm.nih.gov/pubmed/28549662

Thoughts?

Age-adjusted d-dimers have been accepted practice everywhere I work for the last 3-4 years. I know I have scanned fewer folks because of them.

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12 hours ago, kargiver said:

For me, you are either PERC (-) and negative D-dimer or you get worked up for PE if I think you are medium to high risk.  In all the PE literature, the only rule I like is PERC, and adding a dimer is defensible for not CTing someone who is low risk.  

Jeff Kline (the godfather or PE research) is sending home saddle PEs on outpatient therapy now if they meet certain criteria.  No rule has been shown to trump gestalt, and clinical presentation matters most (IMO). I always document why I don't think its a PE in moderate risk folks (always an alternative diagnosis and their dimer is negative) and if high risk by gestalt, they get spun either way.

Just thoughts,

G

 

agree that if I have a bad felling about someone regardless of score they get worked up. I recently started a guy on heparin before the CTA who had b/l PE.

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4 hours ago, EMEDPA said:

Age-adjusted d-dimers have been accepted practice everywhere I work for the last 3-4 years. I know I have scanned fewer folks because of them.

EMED, this is actually different than age adjusted d-dimers. There is a whole algorithm.  Problem is, it was only one study (published 2017). However it was pretty big, ~3500 patients and 12 hospitals (in the Netherlands). 

This is a good write up and it includes the algorithm flow chart.

http://rebelem.com/the-years-study-simplified-diagnostic-approach-to-pe/

Probably needs more research done.

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Thanks for the clarification. I guess there are 2 things I don't like about this system:

1. everyone gets a d-dimer. there are a lot of falsely elevated, even hugely elevated dimers for many things non-pe

2. there is still the dependence on a subjective criteria. this is only as good as the person making the judgement. I would hope my judgement would be better than a new grad pa/np/md....someone who is tired at the end of their shift who lacks experience(maybe has seen lots of bronchitis with pleuritic cp and never has seen a pe) will think pe is not the most likely dx.

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5 hours ago, EMEDPA said:

Thanks for the clarification. I guess there are 2 things I don't like about this system:

1. everyone gets a d-dimer. there are a lot of falsely elevated, even hugely elevated dimers for many things non-pe

2. there is still the dependence on a subjective criteria. this is only as good as the person making the judgement. I would hope my judgement would be better than a new grad pa/np/md....someone who is tired at the end of their shift who lacks experience(maybe has seen lots of bronchitis with pleuritic cp and never has seen a pe) will think pe is not the most likely dx.

Good points. The human error thing is definitely an issue, and I think that is why they bumped it up if you don't have any "clinical signs." But still, saying "PE most likely diagnosis" is leaving a lot open to interpretation, and could probably use some better defining. 

To answer that above, I don't think anyone I work with has used the Geneva score...still PERC and Wells. Lots of unnecessary CT scans in my opinion, but then again I am not a PA or doc, and not the one who has the responsibility. I feel like our patients also get a lot of unnecessary venous duplexes as well...again though I understand I'm not really in the position to have an opinion on those things.

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I really like that the Geneva score uses only objective criteria. However, it appears that even patients with a Geneva score of 0 still have a 7-9%* chance of PE. I'm a PA student and my clinical experience is limited; however, I would not be comfortable discharging a patient basing my decision making on the Geneva score knowing that there is still a 9%* chance my "low risk" patient has a PE and I haven't done any further testing to pursue this. Meanwhile, a Wells' score of 0 translates to a 1.3%* chance of PE. Comparing the two scores, I'd feel much more comfortable risk stratifying my patient using the Wells' score.

*Percentages are from MDCalc. 

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1 hour ago, karebear12892 said:

I really like that the Geneva score uses only objective criteria. However, it appears that even patients with a Geneva score of 0 still have a 7-9%* chance of PE. I'm a PA student and my clinical experience is limited; however, I would not be comfortable discharging a patient basing my decision making on the Geneva score knowing that there is still a 9%* chance my "low risk" patient has a PE and I haven't done any further testing to pursue this. Meanwhile, a Wells' score of 0 translates to a 1.3%* chance of PE. Comparing the two scores, I'd feel much more comfortable risk stratifying my patient using the Wells' score.

*Percentages are from MDCalc. 

BUT ONCE AGAIN WELLS HAS A +3/-3 BASED ON SUBJECTIVE CRITERIA AND THAT IS OPERATOR DEPENDENT AS DISCUSSED ABOVE (sorry about caps, just noticed).

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Personally I like wells because a low risk score gets you a much lower risk of PE than Geneva, like karebear says. But now I’m using Geneva in documentation because our risk management board put together a PE pathway that we are being asked to use.

But in reality it ends up being gestalt a lot of the time since I have a predominant elderly patient population who would all fail PERC. So it ends up being more gestalt so I don’t reflexively order a dimer on everyone over 50 with chest pain or dyspnea.

On a related note, there is something that hasn’t made sense to me for a while. “PERC negative” is universally accepted as putting someone below the PE testing threshold of about 2%. A Wells score of 0-1 according to MDCALC only has a 1.3% chance of PE in an ED population, but most pathways would still have you put a Wells of 0-1 into the PERC rule and get a dimer accordingly. Anyone have some insight that I’m missing?


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