“PE wasn’t a part of this patient’s differential.”
Consider PE in patients with the most-common complaints (chest pain and shortness of breath), but also with less-common complaints such as syncope, dizziness, or anxiety. PE can present with a multitude of complaints, and it is essential to keep a low threshold when deciding to include it in the differential.
“This patient was in shock. I thought he was septic.”
Always consider massive PE in the differential of undifferentiated atraumatic shock.
“Her PERC score was negative, so I didn’t think I had to order any tests.”
Application of the PERC rule must be confined to a patient population already deemed by the practitioner as low risk. A negative PERC score does not have a negative predictive value high enough to be utilized in any other risk category.
“The D-dimer at triage was negative, so I didn’t think I had to worry about PE.”
Reliance on D-dimer tests other than the quantitative turbidimetric or ELISA assays is inappropriate. Interrater reliability with the qualitative assays used in many point-of-care assays is inadequate, and the sensitivity of this test is not adequate, particularly in the undifferentiated patient.
“I knew the quantitative D-dimer test is much better than the bedside assays. Since it was negative, I stopped the work-up there.”
As with the PERC rule, interpretation of a negative D-dimer assay must be done in the context of the clinician’s pretest probability for disease. Current evidence shows that only in patients considered to have a low clinical risk for PE can a negative quantitative D-dimer safely exclude PE.
“The CTPA was negative, so I discharged the patient.”
As with prior tests mentioned, a negative CTPA (or indeterminate V/Q scan) does not rule out the possibility of PE in a patient considered high risk for emboli. The clinician must interpret the negative results in the context of pretest probability of disease.
“I started the heparin, and his vitals were fine, so I admitted him to the floor.”
A significant percentage of initially stable patients with pulmonary emboli will deteriorate during their hospital course, requiring escalation of therapy. Evaluation of the patient’s potential for deterioration will aid the clinician in admitting the patient to the correct setting.
“I held the heparin pending the results of his diagnostic tests. I knew he was really tachycardic,
but I haven’t confirmed the diagnosis yet.”
In a patient with a high clinical suspicion for disease and signs of hemodynamic instability, initiate anticoagulation therapy immediately. Delayed treatment is associated with increased mortality in these patients.
“I started the patient on 120 mg of enoxaparin. She was dialyzed yesterday.”
Failure to evaluate for contraindications to specific treatment options can cause significant complications. Patients with renal compromise should be treated with unfractionated heparin. As with all therapeutics, the emergency clinician must have a good understanding of both the indications and contraindications for any therapy initiated.
“I know she was stable, but I thought she would benefit from thrombolytics.”
Although controversy exists regarding the use of thrombolytic therapy in patients with PE, they are not recommended in stable patients, since the risks outweigh the benefits.