interesting study on chest ct for pe

[EMEDPA]

http://www.ncbi.nlm.nih.gov/pubmed/22687176?dopt=AbstractPlus

 

think about this the next time you order a chest cta for soft pe r/o

[primadonna22274]

Yikes. Wells criteria anyone? ;)

[EMEDPA]

perc criteria is better and more objective. I use it all the time. the only down side is most women over 20 will be + by perc due to birth control pills. all 8 criteria must be neg to r/o by perc

I hate the subjective nature of wells "is another dx more likely"

http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/

[primadonna22274]

Thanks for the reminder E. I always learn something from you. :)

I agree the exogenous estrogen would be a problem for many of these R/O's.

Not doing too much EM these days...rural FP I have not much more than clinical criteria and history to go on.

Another curious thing about PERC criteria is the notable absence of smoking history...seems relevant with all the endothelial damage and pro thrombotic effects....

[ventana]

[h=3]Abstract[/h][h=4]OBJECTIVES:[/h]Contrast-enhanced computed tomography (CECT) of the pulmonary arteries (CTPA) has become the mainstay to evaluate patients with suspected pulmonary embolism (PE) and is one of the most common CECT imaging studies performed in the emergency department (ED). While contrast-induced nephropathy (CIN) is a known complication, this risk is not well defined in the ED or other ambulatory setting. The aim of this study was to define the risk of CIN following CTPA.

[h=4]METHODS:[/h]The authors enrolled and followed a prospective, consecutive cohort (June 2007 through January 2009) of patients who received intravenous (IV) contrast for CTPA in the ED of a large, academic tertiary care center. Study outcomes included 1) CIN defined as an increase in serum creatinine (sCr) of ≥ 0.5 mg/dL or ≥ 25%, 2 to 7 days following contrast administration; and 2) severe renal failure defined as an increase in sCr to ≥ 3.0 mg/dL or the need for dialysis within 45 days and/or renal failure as a contributing cause of death at 45 days, determined by the consensus of three independent physicians.

[h=4]RESULTS:[/h]A total of 174 patients underwent CTPA, which demonstrated acute PE in 12 (7%, 95% confidence interval [CI] = 3% to 12%). Twenty-five patients developed CIN (14%, 95% CI = 10% to 20%) including one with acute PE. The development of CIN after CTPA significantly increased the risk of the composite outcome of severe renal failure or death from renal failure within 45 days (relative risk = 36, 95% CI = 3 to 384). No severe adverse outcomes were directly attributable to complications of venous thromboembolism (VTE) or its treatment. Conclusions:  In this population, CIN was at least as common as the diagnosis of PE after CTPA; the development of CIN was associated with an increased risk of severe renal failure and death within the subsequent 45 days. Clinicians should consider the risk of CIN associated with CTPA and discuss this risk with patients.

 

 

 

 

 

 

 

 

don't forget the Cancers you are likely causing too

 

not sure how you work this into the decision of rather or not to do a CT - no one ever gets sued for a Cancer Dx years later, but it is doing harm to the patient

 

I think falling back on PE skills - ambulatory FOX, great hx taking, knowing wells and PERC and using them, looking closely at the EKG for right heart strain. and my favorite simple test for any resp issue - ask patient to say the alphabet - if they can't get at least half way through one one breath you gotta look for a cause - if they are only getting to C or D you have a sick person that needs attention......

[True Anomaly]

In the EMRAP July 2012 podcast, Jeff Kline was interviewed about all the latest advances in research with venous thromboembolism, including treatment. The most intriguing thing to come out of it is that, in his opinion, for a patient with a Wells score < 4, you should double the D-Dimer range to include more false positives.

[sunny2spot]

I just listened to that EMRAP the other day. I definitely don't see my colleagues/attendings doing that anytime soon. And even less likely for his recommendation of outpatient anticoag treatment for small PEs. Makes people very uncomfortable medicolegally even if the literature supports it.

[True Anomaly]

I just listened to that EMRAP the other day. I definitely don't see my colleagues/attendings doing that anytime soon. And even less likely for his recommendation of outpatient anticoag treatment for small PEs. Makes people very uncomfortable medicolegally even if the literature supports it.

 

Agreed- like with anything else, it sometimes takes driving the point home more and more to get the paradigm to change. Outpatient anticoagulation only works in the compliant patient, and I know the majority of my patients wouldn't understand how to do this at home or be able to keep f/u appointments.

 

Even less likely a paradigm shift with the doubling of the D-dimer value since it was merely his opinion that it should be done, even if he's the most well-read and researched guy on venous thromboembolism there is.

[Guest JMPA]

So here is the real deal. There is much flawed with this study. 1) what was the patient inclusion criterior? Age/race/co-morbidities of patients?

2) prior renal disease? 3) hydration status? Not to mention this very very VERY small number of patients studied. Just to name a few.Contrast induced nephropathy is a very real, yet rare permanent complication of IV contrast. PE is such an important diagnoses that the "risk" of CIN can not begin to be compared to the "benefit" of early PE intervention. With that being said, all should know some characteristics of contrast. Most CIN can be limited if not completely avoided by hydration, whether IV or adequate PO. Most CIN is transient with no lasting effects. To contrast, missed PE is leathal. Sudden death is the first symptom in about one-quarter (25%) of people who have a PE. It is estimated that 300,000 to 600,000 people are affected by PE each year.

[NeoTrion]

Well you have to admit that at CTA chest protocols are a heck of a lot better than the old V/Q scans for PE. At least you get a positive or negative with CT, and apposed to the probability related to the pioped criteria for V/Q's. Granted a V/Q has far less radiation dose, but CTA is the far more sensitive tool. But this was definitely the most ordered study in the hospital, and most of the time it had nothing to do with labs but more about patient complaints.,,,

[andersenpa]

Agreed- like with anything else, it sometimes takes driving the point home more and more to get the paradigm to change. Outpatient anticoagulation only works in the compliant patient, and I know the majority of my patients wouldn't understand how to do this at home or be able to keep f/u appointments.

 

Even less likely a paradigm shift with the doubling of the D-dimer value since it was merely his opinion that it should be done, even if he's the most well-read and researched guy on venous thromboembolism there is.

 

 

Hopefully compliance will improve with nonmonitored AC drugs like dabigatran. Those sort of things could hasten the change in management styles.