PE - האיגוד הישראלי לרפואה דחופה: Recent Episodes

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Daniel R Rice 1, Michael J Pallaci 2, Michael B Weinstock 3, Samuel S Cray 4, Krista M Foster 5, Jonathan J Oskvarek 6, John J Bedolla 7, Amer Z Aldeen 8, Jesse M Pines 9Affiliations Expand PMID: 42114386 * DOI: 10.1016/j.ajem.2026.05.006 Abstract Objective:* We describe the prevalence of seven life-threatening diagnoses in Emergency Department (ED) patients with chest pain in a national ED group.

Methods: Using data from 141 EDs staffed by US Acute Care Solutions (USACS) from January 2021 to December 2024 in 17 U.S. states, we used descriptive statistics to tabulate prevalences of seven life-threatening conditions in ED patients with atraumatic chest pain: acute coronary syndrome (ACS), pulmonary embolism (PE), pneumothorax, thoracic aortic dissection (TAD), esophageal rupture, pericardial tamponade, and ruptured aortic aneurysm. We used logistic regression to estimate the association between ACS, PE, or any life-threatening diagnosis with ED visit and site characteristics.

Results: In 13,744,869 ED encounters, 951,152 (6.9%) had a complaint of atraumatic chest pain with 52,410 (5.5%) of these diagnosed with a life-threatening condition in the ED. ACS was most common (4.5%), followed by PE (0.78%), pneumothorax (0.13%), TAD (0.09%), esophageal rupture (0.007%), pericardial tamponade (0.005%), and ruptured aortic aneurysm (0.002%). The prevalence of life-threatening diagnoses was higher in patients who were older, male, covered by commercial insurance, who had higher-acuity triage emergency severity index (ESI) levels, arrived by ambulance, and were seen in western U.S. EDs.

Conclusion: Approximately 1 in 18 ED patients with atraumatic chest pain presents with a life-threatening condition. ACS is the most common followed by PE, pneumothorax and TAD. Other diagnoses are very rare. These data may serve as a priori pre-test probabilities for ED clinicians in the evaluation of chest pain.

Keywords: ACS; Chest pain; Dissection; Emergency; Life-threatening; Pulmonary embolism.

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Pulmonary embolism ECG findings are one of the most commonly tested Emergency Medicine board topics — and one of the easiest places to get tricked. Let's quickly cover what is the right answer on boards, and how in real life there is an even better option.

The post PODCAST: The PE ECG Finding Everyone Memorizes… But Gets Wrong first appeared on האיגוד הישראלי לרפואה דחופה.

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Writing Committee Members 1; Mark A Creager, Geoffrey D Barnes, Jay Giri, Debabrata Mukherjee 2, William Schuyler Jones 2, Allison E Burnett 3, Teresa Carman, Ana I Casanegra, Lana A Castellucci, Sherrell M Clark 4, Mary Cushman, Kerstin de Wit, Jennifer M Eaves, Margaret C Fang 5, Joshua B Goldberg, Stanislav Henkin, Hillary Johnston-Cox, Sabeeda Kadavath 6, Daniella Kadian-Dodov, William Brent Keeling, Andrew J P Klein 7, Jun Li, Michael C McDaniel, Lisa K Moores 8, Gregory Piazza, Karen S Prenger 9, Steven C Pugliese, Mona Ranade 10, Rachel P Rosovsky, Farla Russo 4, Eric A Secemsky, Akhilesh K Sista, Leben Tefera, Ido Weinberg 11, Lauren M Westafer 12, Michael N YoungAffiliations ExpandAbstract. Aim: The "2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults" is a de novo guideline that provides comprehensive recommendations for the evaluation, management, and follow-up of adult patients (≥18 years of age) with acute pulmonary embolism (PE). A key feature of this guideline is the introduction of the AHA/ACC Acute Pulmonary Embolism Clinical Categories, which enhance the precision of severity classification, prognosis assessment, and evidence-based therapeutic decision-making.

Methods: A comprehensive literature search was conducted from February 2024 to October 2024 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Select key studies published until April 2025 were added by the guideline writing committee as appropriate.

Structure: The focus of this clinical practice guideline is an evidence-based and patient-centered approach for acute PE evaluation and management of the adult patient. This guideline encompasses the period from the onset of symptoms through clinical follow-up, focusing on risk outcomes assessment, clinical diagnosis of acute PE, appropriate use of adjunctive cardiovascular testing, and management in both the acute and early post-acute phases of PE. It addresses evidence-based diagnostic and management strategies (including pharmacological therapies, advanced interventional therapies, and in-hospital support) for acute PE and associated outcomes.

Keywords: AHA Scientific Statements; acute disease; acute pulmonary embolism; anticoagulant; chronic thromboembolic pulmonary hypertension; diagnosis; diagnostic imaging; direct acting oral anticoagulant; heparin; hypertension, pulmonary; imaging; kidney disease; kidney insufficiency; multimodal imaging; oral anticoagulants; perfusion imaging; pulmonary embolism; risk assessment; risk factors; risk stratification; thrombectomy; thromboembolism; thrombolytic therapy; tomography; venous thromboembolism.

The post Circulation : 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines first appeared on האיגוד הישראלי לרפואה דחופה.

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Written by Samuel Rouleau

A meta-analysis of over 70,000 patients found that non-vitamin-K antagonists (NOACs) were slightly more effective at preventing systemic embolic events (SEE) than warfarin in patients with atrial fibrillation (AF).

Clots, clots, clots—everywhere!
Typically, ischemic stroke risk is the focus in patients with AF, but SEE can have similar morbidity and mortality. In fact, the 30-day mortality rate for patients after SEE was 18%, compared to 17% after ischemic stroke. For this meta-analysis, SEE was defined as acute arterial insufficiency with confirmed (clinical or radiographic) evidence of arterial obstruction not due to progressive peripheral arterial disease or instrumentation. Embolic events in the CNS (stroke), eye, heart (MI), and pulmonary circulation (PE) were NOT defined as SEEs.

Out of the 71,683 patients from included RCTs (RE-LY, ROCKET AF, ARISTOTLE, ENGAGE AF-TIMI 48), 188 patients had an SEE, approximately 8.5% of all arterial thromboembolic events. Patients on standard dose of NOAC had lower event rate per year compared to warfarin, which just met statistical significance (0.10% vs. 0.15% patient/year, HR 0.71, 95%CI 0.51–0.99, p = 0.04). Mortality after SEE in those who had been on NOACs was slightly lower than those on warfarin, which was not statistically significant (0.01% vs. 0.03% patient/year, HR 0.43, 95% CI0.18–1.05,p = 0.070). Notably, low-dose NOACs performed worse compared to standard dose with regard to SEE frequency and mortality.

How will this change my practice?
This study is a good reminder that outside of stroke, MI, and PE, we need to have a low threshold to suspect other types of arterial occlusion events in patients with AF. Standard dose NOACs continue to show good performance compared to warfarin and are largely recommended over warfarin outside specific populations (i.e. antiphospholipid syndrome).

Source
Systemic Embolic Events in Atrial Fibrillation: An Individual Patient Data Meta-analysis of 71 683 Participants Randomized to NOAC Versus Warfarin. Circulation. 2026 Feb 24;153(8):567-575. doi: 10.1161/CIRCULATIONAHA.125.075275. Epub 2026 Jan 30. PMID: 41614257.

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1. Grégoire Le Gal, MD, PhD1,2; Helia Robert-Ebadi, MD3; Venkatesh Thiruganasambandamoorthy, MBBS1,4
2. et al
3. Author Affiliations
4. Article Information

JAMAPublished Online: January 5, 20262026;335;(5):416-424. doi:10.1001/jama.2025.21561Key PointsQuestion Does an age-adjusted D-dimer cutoff safely increase the proportion of patients in whom deep vein thrombosis (DVT) can be excluded?

Findings In this multinational prospective outcome study including 3205 outpatients presenting to the emergency department with suspected DVT, the age-adjusted D-dimer cutoff safely excluded DVT. Among patients with D-dimer level between 500 µg/L and their age-adjusted cutoff, none developed venous thromboembolism at 3 months. Use of the age-adjusted cutoff resulted in a 7.4% absolute increase in the proportion of patients in whom the diagnosis could be excluded.

Meaning An age-adjusted D-dimer cutoff may safely rule out DVT and increase diagnostic efficiency, reducing the need for unnecessary imaging.

Abstract. Importance The age-adjusted D-dimer cutoff (age × 10 µg/L in patients 50 years or older), safely increases the diagnostic yield of D-dimer in patients with suspected pulmonary embolism but has not been validated in patients with suspected leg deep vein thrombosis (DVT).

Objective To prospectively validate whether using an age-adjusted D-dimer cutoff allows clinicians to safely rule out DVT.

Design, Setting, and Patients Multicenter, multinational prospective management outcome study conducted in 27 centers in Belgium, Canada, France, and Switzerland between January 2015 and October 2022 (last follow-up visit, January 30, 2023) and including outpatients presenting to the emergency department with suspected DVT.

Interventions Patients were assessed by a sequential diagnostic strategy based on the assessment of clinical pretest probability by the Wells score, a highly sensitive D-dimer test, and leg compression ultrasonography. Patients in whom DVT was ruled out were followed up for a 3-month period.

Main Outcome and Measure The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events during follow-up in patients in whom DVT was ruled out based on a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff.

Results A total of 3205 patients were included. Median age was 59 years, and 1737 (54%) were female. DVT prevalence was 14%. Among the 2169 patients with a non-high or unlikely clinical probability, 531 (24.5% [95% CI, 22.7%-26.4%]) had a D-dimer level less than 500 µg/L, and 161 additional patients (7.4% [95% CI, 6.4%-8.6%]) had a D-dimer level between 500 µg/L and their age-adjusted cutoff. No failures were identified in patients with a D-dimer level 500 µg/L or greater but below the age-adjusted cutoff (0% [95% CI, 0%-2.3%]). Among patients 75 years or older, using the age-adjusted cutoff instead of the 500-µg/L cutoff increased the proportion of negative D-dimer from 33 of 379 (8.7% [95% CI, 6.3%-12.0%]) to 99 of 379 (26.1% [95% CI, 22.0%-30.8%]), without any false-negative test results.

Conclusions and Relevance The age-adjusted D-dimer cutoff may safely rule out DVT and was associated with a larger number of patients in whom DVT could be effectively ruled out.

Trial Registration ClinicalTrials.gov Identifier: NCT02384135.

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We discuss the diagnosis and management of SCAPE in the ED.

Hosts:
Naz Sarpoulaki, MD, MPH
Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/SCAPEv2.mp3Download Leave a Comment Tags: Acute Pulmonary Edema, Critical Care

Show Notes Core EM Modular CME CourseMaximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.Course Highlights:

• Credit: 12.5 AMA PRA Category 1 Credits™
• Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics.
• Cost:
  • Free for NYU Learners
  • $250 for Non-NYU Learners

Click Here to Register and Begin Module 1 The Clinical Case

• Presentation: 60-year-old male with a history of HTN and asthma.
• EMS Findings: Severe respiratory distress, SpO₂ in the 60s on NRB, HR 120, BP 230/180.
• Exam: Diaphoretic, diffuse crackles, warm extremities, pitting edema, and significant fatigue/work of breathing.
• Pre-hospital meds: NRB, Duonebs, Dexamethasone, and IM Epinephrine (under the assumption of severe asthma/anaphylaxis).

Differential Diagnosis for the Hypoxic/Tachypneic Patient

• Pulmonary: Asthma/COPD, Pneumonia, ARDS, PE, Pneumothorax, Pulmonary Edema, ILD, Anaphylaxis.
• Cardiac: CHF, ACS, Tamponade.
• Systemic: Anemia, Acidosis.
• Neuro: Neuromuscular weakness.

What is SCAPE?Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is characterized by a sudden, massive sympathetic surge leading to intense vasoconstriction and a precipitous rise in afterload.

• Pathophysiology: Unlike HFrEF, these patients are often euvolemic or even hypovolemic. The primary issue is fluid maldistribution (fluid shifting from the vasculature into the lungs) due to extreme afterload.

Bedside Diagnosis: POCUS vs. CXRPOCUS is the gold standard for rapid bedside diagnosis.

• Lung Ultrasound: Look for diffuse B-lines (≥3 in ≥2 bilateral zones).
• Cardiac: Assess LV function and check for pericardial effusion.
• Why not CXR? A meta-analysis shows LUS has a sensitivity of ~88% and specificity of ~90%, whereas CXR sensitivity is only ~73%. Importantly, up to 20% of patients with decompensated HF will have a normal CXR.

Management Strategy 1. NIPPV (CPAP or BiPAP)Start NIPPV immediately to reduce preload/afterload and recruit alveoli.

• Settings: CPAP 5–8 cm H₂O or BiPAP 10/5 cm H₂O. Escalate EPAP quickly but keep pressures to avoid gastric insufflation.
• Evidence: NIPPV reduces mortality (NNT 17) and intubation rates (NNT 13).

2. High-Dose NitroglycerinThe goal is to drop SBP to < 140–160 mmHg within minutes.

• No IV Access: 3–5 SL tabs (0.4 mg each) simultaneously.
• IV Bolus: 500–1000 mcg over 2 minutes.
• IV Infusion: Start at 100–200 mcg/min; titrate up rapidly (doses > 800 mcg/min may be required).
• Safety: ACEP policy supports high-dose NTG as both safe and effective for hypertensive HF. Use a dedicated line/short tubing to prevent adsorption issues.

3. Refractory HypertensionIf SBP remains > 160 mmHg despite NIPPV and aggressive NTG, add a second vasodilator:

• Clevidipine: Ultra-short-acting calcium channel blocker (titratable and rapid).
• Nicardipine: Effective alternative for rapid BP control.
• Enalaprilat: Consider if the above are unavailable.

Troubleshooting & Pitfalls The “Mask Intolerant” PatientHypoxia is the primary driver of agitation. NIPPV is the best sedative. * Pharmacology: If needed, use small doses of benzodiazepines (Midazolam 0.5–1 mg IV).

• AVOID Morphine: Data suggests higher rates of adverse events, invasive ventilation, and mortality. A 2022 RCT was halted early due to harm in the morphine arm (43% adverse events vs. 18% with midazolam).

The Role of DiureticsIn SCAPE, diuretics are not first-line.

• The problem is redistribution, not volume excess. Diuretics will not help in the first 15–30 minutes and may worsen kidney function in a (relatively) hypovolemic patient.
• Delay Diuretics until the patient is stabilized and clear systemic volume overload (edema, weight gain) is confirmed.

Disposition

• Admission: Typically requires CCU/ICU for ongoing NIPPV and titration of vasoactive infusions.
• Weaning: As BP normalizes and work of breathing improves, infusions and NIPPV can be gradually tapered.

Take-Home Points

1. Recognize SCAPE: Hyperacute dyspnea + severe HTN. Trust your POCUS (B-lines) over a “clear” CXR.
2. NIPPV Immediately: Don’t wait. It saves lives and prevents tubes.
3. High-Dose NTG: Use boluses to “catch up” to the sympathetic surge. Don’t fear the dose.
4. Avoid Morphine: Use small doses of benzos if the patient is struggling with the mask.
5. Lasix Later: Prioritize afterload reduction over diuresis in the hyperacute phase. The post PODCAST: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) first appeared on האיגוד הישראלי לרפואה דחופה.

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Written by Millie Cossé

This RCT of 100 patients with intermediate-high risk PE showed that mechanical thrombectomy plus anticoagulation was superior to anticoagulation alone in reducing RV/LV ratio and earlier normalization of vitals.

There’s a STORM brewin’
The authors of the STORM-PE trial randomized 100 hemodynamically stable patients with acute PE and elevated RV/LV diameter with elevated cardiac biomarkers to either anticoagulation (AC) alone or anticoagulation with computer-assisted vacuum thrombectomy (CAVT).

The primary outcome of this study was change in RV/LV ratio assessed by CTA at 48 hours post-procedure. The CAVT+AC group had greater reduction in RV/LV ratio (0.52±0.37) than the AC group (0.24±0.40), a difference of 0.27 (95%CI 0.12 to 0.43, P<0.001).

While increased RV/LV ratio correlates with an increased risk of mortality, it may not be enough to justify the increased cost and expertise needed to treat these otherwise hemodynamically stable patients. The authors promise a future publication focused on functional outcomes (e.g. 6-minute walk test, post VTE functional status scale, etc.), which I think will be very important in weighing risks and benefits of this procedure.

How will this change my practice?
When I have a hemodynamically stable patient with an acute PE in my critical access ED, I need more than a surrogate endpoint to recommend transfer for a procedure. I look forward to the next paper coming out, and in the meantime, I will continue to coordinate care closely with regional referral centers.

Source
STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes from the STORM-PE Trial. Circulation. 2025 Nov 3. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub ahead of print. PMID: 41183181.

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Meriem Hammache 1, Camille Simard 2, Sandrine Hamel 3, Suzie Ouellet 3, Gisèle Jolicoeur 3, Karen Wou 4, Kate Sellen 5, Ramy El-Jalbout 6, Jayson Potts 7, Ghada Bourjeily 8, Maral Koolian 9, Vicky Tagalakis 2, Leslie Skeith 10, Grégoire Le Gal 11, Isabelle Malhamé 12Affiliations Expand PMID: 40404047* * DOI: 10.1016/j.chest.2025.05.014

Free article

Abstract Topic importance: Pulmonary embolism (PE) is one of the leading causes of pregnancy-related deaths in high-income countries. Maternal mortality from PE has been attributed to delayed recognition and investigation. The diagnosis of PE may be challenging, as its early signs and symptoms may overlap with physiological changes of pregnancy. As such, promptly ruling out suspected PE using diagnostic testing is of paramount importance. This narrative review provides a contemporary overview of risk assessment tools, diagnostic modalities, counseling needs, and existing best practice guidance for the diagnosis of PE in pregnancy.

Review findings: The revised Geneva score and the pregnancy-adapted YEARS algorithm are promising risk stratification methods that have been found to be safe and effective to support the diagnosis of PE in pregnancy. CT pulmonary angiography and ventilation perfusion scans have comparable safety and effectiveness profiles. Iodinated contrast agents administered for CT pulmonary angiography in pregnant patients with suspected PE are not associated with risks of neonatal adverse events. Pregnant patients may experience distress about fetal health during diagnostic testing, underscoring the importance of counseling to help in decision-making and improve the quality of care. Recent guidelines have supported the use of clinical prediction rules. Both imaging modalities are considered safe in pregnancy, with some guidance advising to choose between the 2 tests based on chest radiography results.

Summary: The choice of diagnostic testing should be based on equipment availability, the ability to perform testing in a timely manner, clinical urgency, chest radiography results, and suspicion of alternative diagnoses.

Keywords: CT pulmonary angiography; imaging; pregnancy; pulmonary embolism; severe maternal morbidity; venous thromboembolism; ventilation-perfusion scintigraphy.

Copyright © 2025 The Author(s). Published by Elsevier Inc. All rights reserved.

The post Diagnosing Pulmonary Embolism During Pregnancy first appeared on האיגוד הישראלי לרפואה דחופה.

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Mary P Dang 1, Anna Cheng 2, Jessica Garcia 1, Ying Lee 1, Mihir Parikh 3, Ali B V McMichael 4, Brian L Han 5, Sheena Pimpalwar 5, Elliot S Rinzler 5, Olivia L Hoffman 6, Sirine A Baltagi 7, Cindy Bowens 6, Abhay A Divekar 8, A Paige Davis Volk 6, Craig J Huang 9, Surendranath R Veeram Reddy 8, Yousef Arar 8, Ayesha Zia 10Affiliations ExpandAbstract Background: Multidisciplinary pulmonary embolism response teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underused concept in pediatrics.

Research question: Is a PERT feasible in pediatrics, and does it improve PE care?

Study design and methods: A strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented the PERT. Data were collected for the 2-year pre-PERT and post-PERT eras, and outcomes were compared.

Results: PERT implementation took 12 months. Our PERT, led by hematology, is composed of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 patients post-PERT were analyzed. Pre-PERT, 10% (3 of 30), 13% (4 of 30), 20% (6 of 30), and 57% (17 of 30), and post-PERT, 3% (1 of 31), 10% (3 of 31), 16% (5 of 31), and 71% (22 of 31) were categorized as high-risk, intermediate-low-risk, intermediate-high-risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible patients with PE and, additionally, on four low-risk PEs. Time to echocardiogram was shorter post-PERT (4.7 vs 2 hours; P = .0147). Anticoagulation was ordered (90 vs 54 min; P = .003) and given sooner (154 vs 113 min; P = .049) post-PERT. There were no differences in time to reperfusion therapies (12 hours pre-PERT vs 8.7 hours post-PERT, P = .10). Five of six (83.3%) eligible (intermediate-high and high-risk) patients received reperfusion therapies in the post-PERT era compared to three of eight (37.5%) eligible patients in the pre-PERT era (P = .0001). There were no differences in major bleeding, mortality, or length of stay in either era.

Interpretation: The pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center and Children's Medical Center pediatric PERT may serve as a best practice model for streamlining care for pediatric PE.

Keywords: PERT; catheter-directed thrombolysis; pediatric pulmonary embolism; pediatrics; pulmonary embolism; pulmonary embolism response team; reperfusion therapies; venous thromboembolism.

The post Chest: Bringing PERT to Pediatrics: Initial Experience and Outcomes of a Pediatric Multidisciplinary Pulmonary Embolism Response Team (PERT) first appeared on האיגוד הישראלי לרפואה דחופה.

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Written by Millie Cossé

The PERC-35 rule was designed to reduce unnecessary testing in individuals ≤35 years old but had an unacceptably high miss-rate.

Do they really need further testing?
We know from prior studies that the prevalence of pulmonary embolism is 10 times lower in patients aged 18-35 years than in patients >65 years, though imaging rates for PE between the two groups are almost the same (2.3% vs. 3.2). Therefore, a risk-stratification score specifically suited to young patients would be helpful to reduce over-imaging rates.

Enter PERC-35, a modification of the PERC rule, which changes the age cutoff from <50 years to ≤35 years and replaces pulse ≤100 with temperature ≤38˚C.

This retrospective cohort study utilized data from the RIETE registry to evaluate the failure rate of the PERC-35. All patients in the RIETE registry had been objectively diagnosed with a pulmonary embolism. A total of 58,918 adult patients with acute PE were included in the study, and PERC-35 performed well when applied to all adult patients. However, when considering how it performed when applied to the 2,935 patients aged 18-35 years, PERC-35 had a failure rate of 7.0% (95%CI 6.0-7.9).

How will this change my practice?
The authors concluded that the PERC-35 rule had a low miss rate when applied to ALL patients in the RIETE database, but when the PERC-35 rule was applied to patients in the database aged 18-35, the authors found a staggering 7% failure rate. Therefore, I will not be implementing this tool in my practice.

Another SpoonfulFrom senior author Olivier Hugli: “PERC-35 is probably safe to use if applied to a population with the same age distribution as the one used in the RIETE registry. Age was the single item for which patients failed the rule in this population. However, if the age distribution is different, with a younger population, then it should be avoided.”

Source
Failure rate of the pulmonary embolism rule-out criteria rule for adults 35  years or younger: Findings from the RIETE Registry. Acad Emerg Med. 2024 Nov 24. doi: 10.1111/acem.15046. Epub ahead of print. PMID: 39582095

The post Can We Use PERC-35 to Rule Out PE in Younger Patients? first appeared on האיגוד הישראלי לרפואה דחופה.

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Lauren M Westafer 1, Thomas Presti 2, Meng-Shiou Shieh 3, Penelope S Pekow 4, Geoffrey D Barnes 5, Alok Kapoor 6, Peter K Lindenauer 7Affiliations Expand DOI: 10.1016/j.annemergmed.2024.05.009 Abstract Study objective:* Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE.

Methods: We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment.

Results: Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81).

Conclusions: Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

The post Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020 first appeared on האיגוד הישראלי לרפואה דחופה.

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EM Board Bombs · 230. PE & PregnancyPE workup? Sure. Oh by the way they’re pregnant…yep. Let’s discuss how this is workup needs to be simplified and not feared. Also, say goodbye to VQ scans.

Want to experience the greatest in board studying? Check out our interactive question bank podcast- the FIRST of its kind here.

Cite this podcast as: Briggs, Blake; Husain, Iltifat. 230. PE and Pregnancy. July 22nd, 2024. Accessed [date].

The post PODCAST: PE & Pregnancy first appeared on האיגוד הישראלי לרפואה דחופה.

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March 18, 2024

Before we jump into PE, I had a pediatric airway foreign body case recently. No more bilateral decubitus x-rays. It’s high-res, low-dose CT. Know where I learned this? JournalFeed Top Picks! I have learned some game-changing things from Dr. Mattu, and special thanks to Dr. Stephanos with her PEM lit pearls. These videos have changed my practice. Check out this new video series for yourself! ~Clay Smith

Written by Rebecca White

One third of eligible patients with high-risk pulmonary embolism (PE) receive systemic thrombolysis (ST) despite demonstrated mortality benefit. This review provides a comprehensive overview of current evidence on assessment and management of high-risk PE, with emphasis on reperfusion therapies.

Don’t just stand there, bust a clot!
High-risk PE, defined by ESC guidelines as cardiac arrest, obstructive shock (SBP <90mmHg), or persistent hypotension without alternative cause, accounts for only 5-10% of PE cases but has a disproportionately large effect on total PE mortality.1-4 Despite high mortality rates that may even be increasing, only small percentage of patients eligible for ST actually receive it.5,6 This narrative review includes 147 articles focusing on clinical assessment, pathophysiology, and management of patients with high-risk PE. Buckle up – it’s a wordy but important summary.

Clinical assessment:

• If patient is risk-stratified as high-risk, proceed directly to CT pulmonary angiography.
• If too unstable for CT, utilize history, exam, ultrasound, and other diagnostics to determine the etiology of shock.

Pathophysiology of right ventricular (RV) failure:

• When pressure in the pulmonary arteries increases significantly, compensatory mechanisms of the RV cannot keep up.
• Thus ensues the so-called “PE death spiral” of RV distention, decreased cardiac output and hemodynamic instability.

Management of hemodynamic instability:

• Give enough fluid to optimize preload, but not worsen RV over-distention (consider a 250-500mL bolus).
• Consider norepinephrine as a first-line vasopressor, followed by vasopressin. Avoid phenylephrine.
• Consider epinephrine for inotropic support, but beware of tachyarrhythmias. Avoid dobutamine or milrinone alone.

Management of respiratory failure:

• Utilize supplemental oxygen with goal SpO2 >90% to combat hypoxemia due to V/Q mismatch.
• Avoid positive pressure ventilation if possible. If intubation is necessary, optimize hemodynamics prior to induction.
• Consider inhaled pulmonary vasodilators for refractory hypoxemia.

Reperfusion therapies:

• Anticoagulation should be given unless absolutely contraindicated, even before diagnostic CT imaging if pretest probability is high. For unstable patients, unfractionated heparin is a first-line agent; keep a close eye to ensure levels are therapeutic. There is no evidence to support DOAC use in this population just yet.
• Standard-dose ST is recommended as first-line reperfusion therapy, barring any absolute contraindications. Reduced-dose thrombolytics can be considered if a relative contraindication exists. There is no established timeframe for ST administration in patients with high-risk PE, and no apparent difference between tenecteplase and alteplase.
• If there are major contraindications to ST or a patient continues to decompensate after ST, consider alternative reperfusion therapies such as surgical embolectomy and catheter-directed interventions.
• ECMO can be used as a bridge to reperfusion therapy in the crashing patient.
• In cardiac arrest, ST should be given if there is clinical concern for PE. Guidelines vary in recommended duration of cardiopulmonary resuscitation (CPR) following ST. Authors recommend continuing ACLS-guided CPR for at least 30 minutes after administration.

How will this change my practice?
Emergency clinicians should feel very prepared to manage high-risk PE, yet eligible patients don’t receive guideline-directed ST nearly as often as they should. With this in mind, I’ll continue to appraise my own management of high-risk PE patients in conjunction with our PE Response Team to ensure we are following guidelines and considering early reperfusion therapy.

Source
Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med. Published online February 3, 2024. doi:10.1016/j.ajem.2024.01.039

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February 7, 2024

Written by Carmen Wolfe

Mortality in patients with high-risk pulmonary embolism (PE) in the United States increased over the last decade. Surprised? Here’s why this might be true, and what we should do about it.

Is PE deadlier than ever?
Yesterday, we covered how dangerous high-risk PE is, and mortality in this group appears to be increasing. This spectacular article decodes recent epidemiologic data and research efforts regarding PE. As defined by the ESC guidelines, patients with high-risk PE experience hemodynamic instability – defined by cardiac arrest, obstructive shock, or persistent SBP < 90 mmHg.1 Mortality in this high-risk subgroup appears to have increased by nearly 100% in the United States from 2009 to 2019.2 This might be due to an aging population with greater comorbidities, increased recognition and classification of deaths, increased incidence due to the SARS-CoV2-2 pandemic, or under-treatment of PE.

How can we turn the tide on this concerning trend? The authors make a few suggestions:

• Presumptively anticoagulate patients prior to imaging results.
• Utilize systemic thrombolysis in high-risk PE if no contraindications (optimal dosing still TBD).
• Consider catheter-directed therapies, though more evidence is needed.
• Create PE Response Teams (PERTs).

What about patients who don’t quite meet high-risk criteria? The ESC defines this group as intermediate-high-risk when right ventricular dysfunction and elevated troponin are both present. What strategies do we have here?

• Continue research to identify prognostic markers that may help guide management.
• Follow consensus guidelines and utilize LMWH or fondaparinux rather than unfractionated heparin in hemodynamically stable patients.
• Increase awareness and await results of ongoing trials regarding reduced-dose systemic thrombolysis, catheter-directed thrombolysis, or mechanical thrombectomy in this intermediate-high-risk cohort.

How will this change my practice?
Knowing these concerning trends, I will do what I can to help reverse them. I’ll carefully examine my own practice to ensure I’m following consensus guidelines, suggest development of a PE Response Team at my hospital, and eagerly awaiting upcoming trial results.

Author Commentary: “Although the care of acute PE has advanced tremendously over the past decade and the overall mortality of non-high-risk PE appears stable, research effort dedicated to improving the management of the higher-risk subgroups is needed.” -Bo Stubblefield

Also, thanks to Bo for reviewing this post.

Source
Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med. Published online December 21, 2023.

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Diagnosing PE:

Step 1: Consciously consider the diagnosis

Step 2: Risk Stratify into low, intermediate, and high risk

Step 3: Choose appropriate testing based on pre-test probability

Classification of PE

1. High Risk/Massive PE: Hemodynamic Instability
2. Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+
3. Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2)

Treatment of PE

1. High Risk/Massive PE: Thrombolytics and often thrombectomy
2. Intermediate Risk/Submassive PE: Heparin and sometimes intervention
3. Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

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August 29, 2023 / Venous Thromboembolism Written by Samuel G. Rouleau Structured surveillance without anticoagulation of patients with isolated subsegmental pulmonary embolism (ssPE) rarely occurs in community practice. After applying CHEST guidelines, ~5% of patients with isolated subsegmental PE are eligible for surveillance. Small PE? Fat chance…of surveillance without anticoagulation Pulmonary emboli confined to the subsegmental […]

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Rosanne van Maanen 1, Emily S L Martens 2, Toshihiko Takada 3, Pierre-Marie Roy 4, Kerstin de Wit 5, Sameer Parpia 6, Noémie Kraaijpoel 7, Menno V Huisman 8, Philip S Wells 9, Grégoire Le Gal 9, Marc Righini 10, Yonathan Freund 11, Javier Galipienzo 12, Nick van Es 13, Jeanet W Blom 14, Karel G M Moons 15, Frans H Rutten 16, Maarten van Smeden 15, Frederikus A Klok 8, Geert-Jan Geersing 16, Kim Luijken 15 Abstract            Background: In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on […]

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Connor O’Hare 1, Kelsey A Grace 1, William J Schaeffer 1 2, S Nabeel Hyder 3, Michael Stover 1, Amber L Liles 4, Minhaj S Khaja 4, James A Cranford 1, Keith E Kocher 1, Geoffrey D Barnes 3, Colin F Greineder 1 5 6 Affiliations expand Free PMC article Abstract                Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending […]

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Robert Smyth, M.D.,  Christopher  Kabrhel,  .D., M.P.H.,  and Timothy Morris, M.D. Case Vignette A Woman with a Pulmonary Embolism Robert Smyth, M.D. A 33-year-old woman presents to her local rural health center with acute-onset dyspnea and chest pain. She has no relevant medical history and takes a combined oral contraceptive for birth control. On examination, she has […]

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May 29, 2023 / Venous Thromboembolism Written by Chris Thom In a retrospective cohort of patients with acute pulmonary embolism (PE) and a low pulmonary embolism severity index (PESI) score, increased heart rate and bilateral PE were factors associated with physicians’ decision for hospitalization. Why does this matter? In the US, approximately half of DVTs are discharged […]

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March 2, 2023 / Critical Care, Surgery, Venous ThromboembolismWritten by Nick Zelt

This is a scientific statement from the American Heart Association (AHA) emphasizing the need for more research on surgical embolectomy (SE) and mechanical circulatory support (MCS) in the treatment of high-risk pulmonary embolism (PE).

Why does this matter?
PE is common. The lifetime risk of PE after the age of 45 is 8.1%. Additionally, an estimated 45% of PEs will progress to more severe clinical presentations, which may include hemodynamic instability due to right heart failure. PE is the third leading cause of cardiovascular death in the U.S. Per AHA and European Society of Cardiology (ESC) guidelines, thrombolytic and transcatheter therapies are recommended as initial measures, while SE and MSC are reserved for more critically ill patients or those with contraindications to the former. The AHA has released a statement on the use of these interventions.

Bridge to better options…remove the clot and fix the problem…or both?
This statement focuses on high-risk patients with acute PE. Use of SE and MCS are not mutually exclusive. The authors acknowledge that historically, MCS and SE have been used, almost exclusively, only in the most high-risk patients.

SE dates back to the early 1900s, decades before heparin was used clinically. Development of a cardiopulmonary bypass machine was imperative for the success of these procedures. Current guidelines recommend SE as a last resort after failing or being excluded from standard treatments. Despite a disproportionately high-risk population (preoperative CPR in 4.9%-45.8%), in-hospital mortality for patients undergoing SE has improved dramatically to now be 2.3%-13.2%, with mortality largely associated with the CPR subgroup. Currently, exact indications to refer for SE are not well defined.

In addition to enabling safe SE, MCS is an alternative treatment to temporarily offload the right ventricle (RV) and buy time for catheter-directed lysis or SE. The diversion of venous flow in VA-ECMO decompresses the failing RV. VV-ECMO, while fixing the oxygenation/ventilation abnormalities of high-risk PE, does not treat RV overload. For some perspective, VA-ECMO for PE-arrest has shown markedly higher survival rates when compared to those for acute MI (70% vs. 17%, respectively).

The authors close with a call for more high-risk PE registries and trials, a refined definition of ‘high-risk PE’ (i.e. a drop in systolic by 40 mmHg is quite different than cardiac arrest), optimization of metrics to assess the efficacy of SE and MCS (i.e. RV recovery vs mortality), and improved awareness and education about these interventions.

Source
Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2023;10.1161/CIR.0000000000001117. doi:10.1161/CIR.0000000000001117

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January 24, 2023 / Venous ThromboembolismWritten by Ketan Patel

The National Early Warning Score (NEWS) was comparable to the validated Pulmonary Embolism Severity Index (PESI) and the simplified PESI (sPESI) in predicting 7-day ICU admission and 30-day mortality in patients with acute pulmonary embolism (PE).

Why does this matter?
NEWS has been shown to be a good predictor of clinical deterioration in hospitalized patients, regardless of the underlying medical process. Risk stratification tools specific to PE, like PESI or sPESI, are important for prognostication of PE patients. The ability of NEWS to be applicable across a variety of disease processes could simplify decision-making. So, how does the broad scoring system, NEWS, apply to a this specific population with PE?

Extra! Extra! What’s the NEWS?! – Another tool to predict which PE patients don’t require more intensive monitoring…
This study was a post-hoc analysis of the YEARS Study.1,2 Seven of the 12 Dutch hospitals is the original YEARS Study collected data needed to calculate the PESI, sPESI, or NEWS scores. The data were analyzed to assess the prediction utility of each score for all-cause ICU admission within 7 days, as well as 30-day mortality.

In their statistical analysis, the authors found that NEWS had a sensitivity and specificity of 92% and 53%, respectively, for ICU admission and 100% and 52%, respectively, for 30-day mortality. PESI yielded a sensitivity and specificity of 75% and 38% for ICU admission and 100% and 37% for mortality, respectively. The sPESI was comparable to PESI. See key figure.

From cited articleNext Steps: A NEWS < 3 was highly sensitive in predicting patients at low risk of ICU admission and 30-day mortality in PE patients in this post-hoc analysis. Of note, NEWS is also is being used as a key assessment in the ongoing HI-PEITHO Trial.

Edited and peer-reviewed by Bo Stubblefield

Source
Use of the National Early Warning Score for predicting deterioration of patients with acute pulmonary embolism: a post-hoc analysis of the YEARS Study. Emerg Med J. 2022 Nov 7:emermed-2021-211506. doi: 10.1136/emermed-2021-211506. Epub ahead of print.

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Written by Christopher Thom

Assessing pretest probability using a modified, age-adjusted clinical decision tool (“Adjust-Unlikely”) vs YEARS reduces CT imaging in patients with suspected pulmonary embolism (PE). “Adjust-Unlikely” missed no PEs. YEARS had a larger reduction of imaging but missed a few PEs.

Why does this matter?
PE is a potentially life-threatening diagnosis. Multiple guidelines recommend that patients who are not high-risk should undergo risk stratification at the bedside and a D-dimer prior to CT imaging. ED physicians frequently overestimate patients who are “high risk” and forgo a more formal calculation of risk. The authors sought to reduce the burden of using a complex clinical decision tool (i.e. Wells) by employing an “Adjust-Unlikely” approach which made selective use of age-adjusted D-dimer.

Consider adjusting beyond your YEARS using an “adjust-unlikely” approach
This was a prospective study of 1,961 patients conducted at two Canadian emergency departments (EDs). All eligible patients being tested for suspected PE were worked up using a standard PE order set (D-dimer, renal function, CBC). If the D-dimer was ≥500 ng/mL, CT or VQ was ordered. Patients were enrolled in a consecutive series, and physicians prospectively recorded YEARS criteria before D-dimer and imaging. Diagnosis of PE was determined by diagnostic imaging performed in the ED or by medical record review at 30 days. Overall, 8% of patients were diagnosed with acute PE on CT during their index ED visit.

Authors compared two diagnostic strategies: “Adjust-Unlikely” vs. YEARS. The “Adjust-Unlikely” strategy involved using the age-adjusted D-dimer (age x 10 in patients older than 50) in cases where PE was not the most likely diagnosis. For those with PE as the most likely diagnosis, the standard D-dimer level of 500 ng/ml was used as the cutoff (Fig below). The sensitivity of YEARS for PE was 92.6% (95%CI 87-96); specificity 45%. The “Adjust-Unlikely” strategy had a sensitivity of 100% (95%CI 97.2-100); specificity 32%.

From cited articleAlthough, it is not clear why the use of YEARS yielded a lower sensitivity than prior studies, the use of age-adjusted D-dimer in the “PE unlikely” cohort missed 0 PEs. The study was not a direct comparison of the standard use of age-adjusted D-dimer, but age-adjusted D-dimer in low to moderate risk patients has also been demonstrated as a safe approach and is supported by guidelines. Prospective implementation of “adjust-unlikely” would be a large lift, but our fingers are crossed for a future trial!

Peer reviewed by Bo Stubblefield

Editor’s note: I like this new approach. It may not reduce imaging as much as YEARS, but it looks like it will miss fewer PEs. ~Clay Smith

Source
Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department [published online ahead of print, 2022 Nov 10]. Ann Emerg Med. 2022;S0196-0644(22)01118-0.

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http://orcid.org/0000-0002-1806-1050Roisin Bavalia1, Milou A M Stals2, Frits I Mulder1,

Ingrid M Bistervels1,3, Michiel Coppens1, Laura M Faber4, Stephan V Hendriks2,5, Herman M A Hofstee6,

Menno V Huisman2, Tom van der Hulle2, Albert T A Mairuhu5, Marieke J H A Kruip7, Saskia Middeldorp1,8,

Frederikus A Klok2, Barbara A Hutten9, Frits Holleman10 Correspondence to Dr Frits Holleman, Internal Medicine, Amsterdam UMC Locatie AMC, Amsterdam 1105 AZ, The Netherlands; f.holleman@amsterdamumc.nl

AbstractBackground The Pulmonary Embolism Severity Index (PESI) and the simplified PESI (sPESI) are validated scores for mortality prediction in patients with pulmonary embolism (PE). National Early Warning Score (NEWS) is a general prognostic risk score for multiple clinical settings. We investigated whether the NEWS had a comparable performance with the PESI and sPESI, for predicting intensive care unit (ICU) admission and death in patients with acute PE.

Methods In haemodynamically stable patients with confirmed PE from the YEARS Study (2013–2015), we evaluated the performance of the NEWS, PESI and sPESI for predicting 7-day ICU admission and 30-day mortality. Receiver operating characteristic curves were plotted and the area under the curve (AUC) was calculated.

Results Of 352 patients, 12 (3.4%) were admitted to the ICU and 5 (1.4%) died. The AUC of the NEWS for ICU admission was 0.80 (95% CI 0.66 to 0.94) and 0.92 (95% CI 0.82 to 1.00) for 30-day mortality. At a threshold of 3 points, NEWS yielded a sensitivity and specificity of 92% and 53% for ICU admission and 100% and 52% for 30-day mortality. The AUC of the PESI was 0.64 (95% CI 0.48 to 0.79) for ICU admission and 0.94 (95% CI 0.87 to 1.00) for mortality. At a threshold of 66 points, PESI yielded a sensitivity of 75% and a specificity of 38% for ICU admission. For mortality, these were 100% and 37%, respectively. The performance of the sPESI was similar to that of PESI.

Conclusion In comparison with PESI and sPESI, NEWS adequately predicted 7-day ICU admission as well as 30-day mortality, supporting its potential relevance for clinical practice.

Data availability statementAll data relevant to the study are included in the article or uploaded as supplemental information.

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November 16, 2022 / Cardiology, Critical CareWritten by Laura Murphy

https://journalfeed.org/article-a-day/2022/how-massive-pe-kills-a-review-of-right-heart-failure/
Decompensated right heart failure (RHF) increases morbidity and mortality, but it can be challenging to diagnose and treat. This review summarizes the unique physiology of RHF and treatment implications.

Why does this matter?
These patients are walking a razor’s edge. You need to be able to diagnose, assess, and treat this life-threatening condition.

Try to get it right
RHF is impaired right ventricular (RV) contractility due to myocardial dysfunction, elevated pulmonary pressures, or volume overload. The most common cause is left heart failure, followed by chronic lung disease, thromboembolism, or pulmonary arterial hypertension. The RV is thin-walled compared to the left ventricle and is more sensitive to changes in afterload (pulmonary vascular resistance) or decreased perfusion due to systemic hypotension or elevated RV pressure. In acute RHF, the RV is preload-dependent to maintain stroke volume, but volume overload can lead to RV distension and bowing of the LV septum, decreasing cardiac output (ventricular interdependence). The cyclic pathophysiology of right heart failure is demonstrated below.

From cited articleTreatment should target the underlying cause while optimizing hemodynamics and oxygenation. POCUS is particularly important in RHF to assess RV function and determine volume status.

• Systemic hypotension can be due to hypovolemia or volume overload with RV overdistension, so use POCUS to determine need for additional fluids vs diuresis. Titrate fluids slowly (250 cc at a time), and use vasopressors (norepinephrine) early in the hypotensive patient.
• Avoid hypoxia and acidosis, which worsen pulmonary vasoconstriction and increase afterload. Consider pulmonary vasodilators (inhaled nitric oxide or phosphodiesterase inhibitors) for afterload reduction, and be sure to continue home infusions (i.e. epoprostenol) for patients who are on them. Dobutamine or milrinone can be used for inotropic support.
• Avoid endotracheal intubation, if possible, due to risk of peri-intubation cardiac arrest. High-flow nasal cannula or noninvasive ventilation should be considered first. In patients requiring intubation, use vasopressor support (and pulmonary vasodilators if able) prior to intubation and minimize plateau pressures and PEEP to maintain preload.
• Treat arrhythmias with rapid electrical cardioversion rather than beta blockers or calcium channel blockers, which can worsen cardiac output.

Source
Right heart failure: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Aug;58:106-113. doi: 10.1016/j.ajem.2022.05.030. Epub 2022 May 25.

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In the US, pulmonary embolism (PE) affects approximately 370 000 patients annually and is estimated to cause 60 000 to 100 000 deaths per year. In this podcast, JAMA Senior Editor Kristin Walter, MD, MS, discusses the clinical presentation, diagnostic strategies, and treatment of PE with Yonathan Freund, MD, PhD, professor of emergency medicine at […]

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Yonathan Freund, MD, PhD1,2; Fleur Cohen-Aubart, MD, PhD1,3; Ben Bloom, MD, PhD4 Author Affiliations Article Information JAMA. 2022;328(13):1336-1345. doi:10.1001/jama.2022.16815 Abstract Importance  Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to […]

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August 26, 2022 / Cardiology, Venous Thromboembolism Written by Graham Van Schaik Spoon Feed In patients with acute pulmonary embolism (PE), only supraventricular tachycardia (SVT) was an independent predictor of clinical deterioration (CD); however, other ECG findings (below) were associated with abnormal RV function (abnl-RV) on echo. Why does this matter? As emergency physicians, PE should always be […]

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This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. A 41-year-old man presents to the emergency department with a 3-week history of breathlessness. He recently completed a course […]

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Post amended 5/25/22 11am. PERC considers recent surgery or trauma in the past 28 days, not necessarily hospitalization. Written by Clay Smith Spoon Feed Risk for venous thromboembolism (VTE) was highest during hospitalization, but the risk remained elevated 3-fold at 3 months post-discharge. Why does this matter? The PERC rule considers recent surgery or trauma in […]

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Written by Bo Stubblefield Spoon Feed The European Society of Cardiology (ESC) has generated a position detailing optimal follow-up of patients following acute pulmonary embolism (PE). They advocate for a holistic approach with consideration of both short- and long-term events encountered by patients diagnosed with acute PE. Why does this matter? Patients with acute PE […]

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Written by Clay Smith Spoon Feed This is a spoon-feed version of the management of massive and submassive PE in children. Why does this matter? PE has become more common in children and rarely causes severe disease. Current pediatric guidelines mirror those of adults. This group of experts seeks to consider how things might need to […]

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Written by Davin Brar Spoon Feed Among patients with symptomatic PE who are low risk by sPESI, the addition of right ventricular assessment predictors (echo, CT, troponin, and BNP) significantly improved prognostication for clinical deterioration within 5 days. Why does this matter? Appropriate disposition for patients diagnosed with pulmonary embolism (PE) is both extremely important […]

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Written by Sam Parnell Spoon Feed Elevated heart rate is associated with increased risk of mortality for patients with acute symptomatic pulmonary embolism. Be wary of patients with acute pulmonary embolism who are tachycardic. Why does this matter? Pulmonary embolism (PE) is associated with significant morbidity and mortality and is the third most common cause […]

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Written by Clay Smith Spoon Feed In PERC positive patients, use of YEARS with age-adjusted D-dimer was noninferior to an age-adjusted D-dimer strategy alone. Why does this matter? This study answers so many questions! I think I am in love. It subjects YEARS to a rigorous RCT approach. It shows the performance of a combined […]

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