Emergency department focused bedside echocardiography in massive pulmonary embolism

Background

Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management. Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist’s interpretation or a confirmatory imaging study.

Objective

We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE.

Case Report

A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram.

Conclusion

In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.     

急性肺栓塞溶栓治疗的循证医学

肺栓塞是一种具有较高的发病率和病死率的常见病。尽管抗凝治疗已经被公认为肺栓塞的标准治疗 ,但由于溶栓治疗能够快速溶解血栓 ,故被认为是一种更理想的治疗选择。 3 0年来很多试验对此作了针对性的研究 ,但结果存在争议 ,在这篇文章里 ,笔者主要对期间的多中心的临床试验作一回顾和总结。     

1例急性大面积肺栓塞的急救护理

肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称[1].病人出现休克和低血压,为大面积肺栓塞[2],具有起病急、病情重、病死率高的特点,及时、有效地溶栓、抗凝,密切观察病情及精心护理是治疗该病的根本措施.我院收治1例急性大面积肺栓塞病人,经急救护理痊愈出院.现将护理介绍如下.     

急性肺栓塞的影像学诊断与介入治疗

目的 探讨合理的影像学诊断和介入治疗对急性肺动脉栓塞患者的临床价值.方法 对29例急性肺动脉栓塞患者采用CT肺血管成像、肺动脉造影及导管碎栓、导管溶栓,以诊断和治疗肺动脉栓塞.结果 29例患者中28例CT检查有阳性表现,所有患者均成功插管至肺动脉.介入治疗后临床症状明显改善,其中9例置入下腔静脉滤器,并发脑出血并死亡1例.结论 CT肺血管成像、肺动脉造影、经导管栓子除祛术和下腔静脉滤器置入术是诊断、治疗和预防急性肺动脉栓塞安全、迅速、有效的方法.     

Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study

Background and objectives     

Pulmonary Embolism Rule-out Criteria vs D-dimer testing in low-risk patients for pulmonary embolism: a retrospective study

Study objectives

The Pulmonary Embolism Rule-out Criteria (PERC) score has shown excellent negative predictive value; however, its use in the European population with high prevalence of PE is controversial. In Europe, PERC is not part of routine practice. For low-risk patients, guidelines recommend D-dimer testing, followed if positive by imaging study. We aimed to study the rate of diagnosis of PE after D-dimer testing in PERC-negative patients that could have been discharged if PERC was applied.

Method

This was a multicenter retrospective study in Paris, France. We included all patients with a suspicion of PE who had D-dimer testing in the emergency department, low pre-test probability, and a negative PERC score (that was retrospectively calculated). Patients with insufficient record to calculate PERC score were excluded. The primary end point was the rate of PE diagnosis before discharge in this population. Secondary end points included rate of invasive imaging studies and subsequent adverse events.

Results

We screened 4301 patients who had D-dimer testing, 1070 of whom were PERC negative and could be analyzed. The mean age was 35 years and 46% were men. D-dimer was positive (> 500 ng/L) in 167 (16%) of them; CTPA or V/Q scan was performed in 153 (14%) cases. PE was confirmed in 5 cases (total rate 0.5%, 95% confidence interval 0.1%-1.1%). Fifteen patients (1%) experienced non-severe adverse events.

Conclusion

D-dimer testing in PERC-negative patients led to a diagnosis of PE in 0.5% of them, with 15% of patients undergoing unnecessary irradiative imaging studies.     

Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department

Background

Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging.

D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry

Summary.  Background:  A number of variables have been evaluated for risk stratification in patients with acute pulmonary embolism (PE). Whereas increased D-dimer levels have been associated with mortality at 3 months, its role in predicting short-term outcome (the period of time during which any therapeutic decision has to be taken) remains unclear. Methods:  RIETE is an ongoing, prospective registry of consecutive patients with acute venous thromboembolism. We assessed the prognostic value of D-dimer levels at baseline, measured with an automated latex agglutination test (IL Test D-dimer^®), on the 15-day outcome in patients with acute PE. Overall mortality, fatal PE and major bleeding rates were compared by quartile. Results:  As of February 2008, 1707 patients with acute PE underwent D-dimer testing. Of these, 72 patients (4.2%) died during the first 15 days, 11 (0.6%) had recurrent PE, and 29 (1.7%) had major bleeding. Overall mortality increased with increasing D-dimer levels, from 2.7% in the first quartile (< 1050 ng mL⁻¹) to 7.0% in the fourth quartile (≥ 4200 ng mL⁻¹). The rates of fatal PE and major bleeding also increased. On multivariate analysis, patients with D-dimer levels in the fourth quartile had an increased risk for overall death (odds ratio, 1.8; 95% CI, 1.1–3.2), fatal PE (odds ratio, 2.0; 95% CI, 1.0–3.8) or major bleeding (odds ratio, 3.2; 95% CI, 1.5–7.0). Conclusions:  PE patients with D-dimer levels in the fourth quartile had an increased incidence of overall death, fatal PE and major bleeding within 15 days both before and after multivariate adjustment.     

Pulmonary angiogram in the diagnosis of acute pulmonary embolism

The indication, complication, diagnostic finding, pit fall of pulmonary angiogram(PAG) for the diagnosis of acute pulmonary embolism (PE) were described. Current non-invasive test such as V/Q scan, CT and MR have been accepted as useful tools for diagnosis and decision making of the treatment of PE. The indications of PAG seems to be limited as the cases with 1) discrepancy between clinical findings and the results of V/Q scan, 2) high suspicious of PE with some risk of anti-coagulant therapy or presenting complication of this therapy, 3) prior to IVR. However, the PAG is still accepted as final clinical test to make a decision of PE or not.     

急诊17例肺动脉栓塞临床分析

目的：提高急诊医师对肺栓塞的认识、早期诊断及治疗。方法：回顾性分析急诊17例肺动脉栓塞患者的临床资料。结果：女性患者居多；基础疾病有下肢静脉血栓、肿瘤、脑梗塞等；其临床表现不典型，多表现为呼吸困难、胸痛、咳嗽、咯血等；对其明确诊断首选放射性核素肺灌注显像；及时进行溶栓和抗凝治疗，效果好，预后佳。结论：在急诊临床工作中应提高对肺栓塞的发病警惕，早期诊断，及时治疗是改善患者预后的关键。     

Pulmonary Embolism Severity Index and troponin testing for the selection of low‐risk patients with acute symptomatic pulmonary embolism

Summary. Background: The combination of the Pulmonary Embolism Severity Index (PESI) and troponin testing could help physicians identify appropriate patients with acute pulmonary embolism (PE) for early hospital discharge. Methods: This prospective cohort study included a total of 567 patients from a single center registry with objectively confirmed acute symptomatic PE. On the basis of the PESI, each patient was classified into one of five classes (I–V). At the time of hospital admission, patients had troponin I (cTnI) levels measured. The endpoint of the study was all‐cause mortality within 30 days after diagnosis. We calculated the mortality rates in four patient groups: group 1, PESI class I–II plus cTnI < 0.1 ng mL^?1; group 2, PESI classes III–V plus cTnI < 0.1 ng mL^?1; group 3, PESI classes I–II plus cTnI ≥ 0.1 ng mL^?1; and group 4, PESI classes III–V plus cTnI ≥ 0.1 ng mL^?1. Results: The study cohort had a 30‐day mortality of 10% [95% confidence interval (CI), 7.6–12.5%]. Mortality rates in the four groups were 1.3%, 14.2%, 0% and 15.4%, respectively. Compared with non‐elevated cTnl, the low‐risk PESI had a higher negative predictive value (NPV) (98.9% vs. 90.8%) and negative likelihood ratio (NLR) (0.1 vs. 0.9) for predicting mortality. The addition of non‐elevated cTnI to low‐risk PESI did not improve the NPV or the NLR compared with either test alone. Conclusions: Compared with cTnl testing, PESI classification more accurately identified patients with PE who are at low risk of all‐cause death within 30 days of presentation.     

Nitrous oxide inhalant abuse and massive pulmonary embolism in COVID-19

A patient presented to the emergency department with altered mental status and lower extremity weakness in the setting of nitrous oxide inhalant abuse and Coronavirus Disease-2019 (COVID-19) infection. He subsequently developed hypotension and severe hypoxia, found to have a saddle pulmonary embolus (PE) with right heart strain requiring alteplase (tPA).