Category: Vascular
Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)
Posted: 7/14/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Evaluating for Pulmonary Embolism During Pregnancy
Highest risk of PE is within the first week postpartum
Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:
**For explanation of PERC rule, see earlier pearl.
Kline J, Carolinas Medical Center, 2006-2008 published data
Category: Vascular
Keywords: Pulmonary Embolism, Cancer (PubMed Search)
Posted: 7/7/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Ruling Out PE in Cancer Patients: Use D-Dimer??
Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.
Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?
The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.
Abstract |
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PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity. CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity. |
King V, Vaze AA, Moskowitz CS, et al. D-dimer assay to exclude pulmonary embolism in high-risk oncologic population: correlation with CT pulmonary angiography in an urgent care setting. Radiology. 2008 Jun;247(3):854-61
Category: Vascular
Keywords: Aortic Dissection, D-Dimer (PubMed Search)
Posted: 6/24/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Does a normal d-dimer rule out aortic dissection?
A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.
A few pearls and pitfalls regarding this:
Sodeck, Eur Heart J 2007
Category: Vascular
Keywords: AAA (PubMed Search)
Posted: 6/9/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Clinical Presentation of AAA
Everyone is familiar with the "classic," textbook, presentation of AAA:
This presentation, however, is not all that common. Many patients simply present with unexplained abdominal and/or flank pain.
Consider the diagnosis in anyone with risk factors (i.e. older folks, family history, etc) who presents with abdominal and/or flank pain. In most cases, CT scanning of this group of patients is the way to go.
And, one last pearl: put the US probe on early. May make a huge difference in time to diagnosis.
Be afraid, be very afraid.
J Vasc Surg, 2007
Category: Vascular
Keywords: CT Venogram, Ultrasound, DVT, Deep Venous Thrombosis( (PubMed Search)
Posted: 6/2/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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What study should we be getting to evaluate for DVT in patients with suspected VTE (venous thromboembolic disease)?
Ultrasound of the legs seems to be equivalent to CT Venography (CTV).
Drawbacks of CT Venography (CT scanning into the abdomen/pelvis/legs after pulmonary CTPA):
Despite the fact that leg ultrasound obviously doesn't evaluate for deep pelvis clots and intraabdominal clots (IVC, etc), outcome studies and other studies in recent years show ultrasound is just as good as CTV.
Goodman LR, et al. CT Venography and Compression Sonography are Diagnostically Equivalent: Data from PIOPED II. Am J Roent 2007
Category: Vascular
Keywords: AV Fistula (PubMed Search)
Posted: 5/13/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Management of Ruptured AV Fistula
This pearl pertains to a case I had 2 weeks ago. A 65 yo male presented with a massively swollen left forearm in the region of his AV fistula. On ultrasound he had a 6 X 6 cm aneurysm. He was seen by vascular and transplant surgery and taken to the OR for repair.
So, the question came up, what would an emergency physician do if this bad boy actually ruptured? Well, obviously we would hold pressure. But what if that didn't work? Well, shouldn't the patient go to the OR? The answer is a resounding yes, but what if there is no surgeon around. There is not much literature on how to handle this devastating vascular catastrophe.
As a rule of thumb, if an AV Fistula ruptures (not leaks) and the patient is exsanguinating in front of you:
J Vasc Surg 2005
Category: Vascular
Keywords: Hypertension (PubMed Search)
Posted: 5/6/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Side Effects of Hydrochlorothiazide
Consider the following when prescribing HCTZ from the emergency department:
The side effects of hydrochlorothiazide include hypokalemia,hypercalcemia, hypomagnesemia, metabolic alkalosis, hyponatremia, hyperuricemia (may worsen gout), hyperglycemia, hypercholesterolemia, hypertriglyceridemia.
Journal of Hypertension, 2006
Category: Vascular
Keywords: hemorrhage (PubMed Search)
Posted: 4/21/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Hemorrhage Volume on Head CT
Ever wanted to speak the same language as our neurosurgical colleagues? Ever wonder what they are doing, calculating, or thinking about as they look at the head CT of the large intracranial hemorrhage?
Most of the neurosurgeons want to know basic information about patients with head bleeds. One thing they always calculate is the hemorrhage volume...i.e. how many mLs of blood are in the bleed? This can be easily done in the ED by using the following formula: called the ABC formula.
A X B X C/2 X 0.6= mL of blood
A= largest width of the bleed (in cm)
B=largest width perpindicular to A
C=number of cuts you see blood on
So, if A=2cm, B=2cm and the bleed is seen on 3 cuts.....
2 X 2 X 3/2 X 0.6=3.6 mL of blood (not very much in the opinion of a neurosurgeon)
Most of the big bleeds that neurosurgeons drain or take to the OR are 50 cc or so. So, when you call a neurosurgeon and tell them that the patient has 60 mLs of blood, you will definitely get their attention.
Category: Vascular
Posted: 4/15/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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PEA Arrest...Look for AAA rupture and Cardiac Tamponade
If a patient presents in cardiac arrest (particularly PEA), consider the following diagnoses in addition to the causes commonly taught in ACLS:
A 2004 study in Resuscitation by Meron et al. showed the following:
Take home point for the emergency physician:
Meron, et al. Resuscitation 2004
Category: Vascular
Keywords: DVT, Pulmonary Embolism (PubMed Search)
Posted: 4/7/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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DVT and Asymptomatic Pulmonary Embolism
A few important pearls about PE:
Journal of Thrombosis and Hemostasis and Chest-2006, 2007
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 3/25/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Treatment of Pulmonary Embolism
Treatment of acute PE:
If administering thrombolytic therapy (currently tPA is the only FDA approved drug) for massive PE, most authorities recommend UFH (Unfractionated Heparin) because the infusion needs to be turned off while the tPA hangs for 2 hours.
Although other agents are being promoted for the treatment of acute PE, like direct thrombin inhibitors, many institutions do not have these drugs available yet. Plus, they are expensive and have not been shown to be superior to standard therapy (at least yet)
References: Kline, Journal of Thrombosis and Hemostasis, 2005, 2006, 2007
Category: Vascular
Keywords: BP, Hypertension, Angioedema (PubMed Search)
Posted: 2/26/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Direct Renin Inhibitor-Aliskiren (Tekturna)
This drug is the 1st in a new class of antihypertensives called direct renin inhibitors-1st approved in 2007. This drug, along with three others being developed, inhibits the entire Renin-Angiotensin-Aldosterone System (RAAS) which has been shown to lead to definitive 24 hour blood pressure control.
Why should emergency physicians care, you ask?
J Hypertension March 2007
Category: Vascular
Keywords: AAA, aneurysm (PubMed Search)
Posted: 2/12/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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AAA...be afraid, be very afraid
Abdominal Aortic Aneurysm (AAA) is known as the great masquerader in the elderly for good reason....
Category: Vascular
Keywords: Inferior Vena Cava, Physical Examination, Thrombosis (PubMed Search)
Posted: 2/5/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Physical Examination finding in inferior vena cava thrombosis
Consider IVC thrombosis if you ever see vertically oriented, dilated abdominal wall veins, or dilated veins on the back. As opposed to abdominal wall veins that radiate out from the umbilicus in patients with cirrhosis-known as caput medusae.
Etiologies include hepatic tumors abutting the IVC, renal cell tumors, open abdominal surgery, catheter related, IVC filter-related.
Category: Vascular
Keywords: Fenoldopam, Hypertension (PubMed Search)
Posted: 1/28/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Fenoldopam Pearls
Intravenous Fenoldopam has been shown in recent years to be a very effective antihypertensive medication. Studies have compared it to Nitroprusside (Nipride), the older generation "gold standard" antihypertensive, and have found to be just as effective.
Journal of Hypertension 2007
Category: Vascular
Keywords: Pulmonary, Pulmonary Embolism (PubMed Search)
Posted: 1/21/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Pulmonary CTA Sensitivity and PIOPED II
The publication of PIOPED II has led some to doubt the sensitivity of pulmonary CTA for pulmonary embolism. This study reported an overall sensitivity of 83% which could be increased to nearly 90% with the addition of CTV (CT Venography). 83% is a horrible sensitivity. So, why should you care?
Category: Vascular
Keywords: PE, Pulmonary Embolism (PubMed Search)
Posted: 1/14/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Optimal pulmonary artery opacification for detecting pulmonary embolism-how good was the CT you ordered?
The PE literature is pretty clear about one thing: a CT with well-timed opacification of the pulmonary arteries is very sensitive for detecting pulmonary embolism. This means that there needs to be enough contrast in the central pulmonary arteries to be able to detect clot. So how can you be really sure the PE Protocol CT you ordered is adequate? Have you really ruled out PE?
What does this mean for the emergency physician?
Some predict that in the future WE (the emergency physician) may in fact be held accountable for knowing whether or not a CTPA (CT Pulmonary Angiography) is optimal or not.
References:
(1) Kline-Carolinas Medical Center (2) Journal of Thrombosis and Hemostasis 2007 (3) AJR 2006,2007
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 1/7/2008 by Rob Rogers, MD
(Updated: 12/9/2024)
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Risk Factors for Pulmonary Embolism
Can you imagine one of our patients saying"Dr. Abaraham, I have what is known in the hematology community as a Factor 5 Leiden mutation"?
Category: Vascular
Keywords: catheter, lytics (PubMed Search)
Posted: 12/31/2007 by Rob Rogers, MD
(Updated: 12/9/2024)
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Thrombolytic infusion for occluded central venous catheters
For patients with long-term indwelling central venous catheters (dialysis catheters, Hickmans, etc) who develop catheter occlusion, consider infusion of thrombolytic therapy for catheter salvage.
How do you do it, you ask?
This treatment is very safe and is well tolerated.
Journal of Vascular Access, 2006
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 12/24/2007 by Rob Rogers, MD
(Updated: 12/9/2024)
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The PERC Rules revisted
How can I rule out PE without ANY testing, you ask? Do I have to get a d-dimer on that low risk patient?
Do these things keep you up at night like they do me?
Consider using the PERC rule (Pulmonary Embolism Rule Out Criteria)
This set of rules was mentioned in an earlier pearl, but there are now 3 large studies (and one on the way) that validate the use of these rules.
So, if you have a patient who is LOW risk for PE but you would like to document something in the chart that proves you thought about the diagnosis and clinically ruled it out:
If the patient is LOW risk for PE by your clinical gestalt and if the answer to ALL of the following questions is YES, then the patient is considered PERC negative:
PERC negative + Low Risk clinical gestalt = PE ruled out
Caution!
Jeff Kline, PERC rule. Journal of Thrombosis and Hemostasis. 2007/2008