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Accelerated Protocols: PE Pathways

Cameron Berg, MD, Mizuho Morrison, DO, and Mike Weinstock, MD
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Let’s admit we, we are obsessed with pulmonary emboli and missing this dreaded diagnosis.  This fear has led to undue increased use of CT angiography and the ease of obtaining one has increased its use. However there are many downsides to over-scanning. There is real harm we are exposing our patients to, not just with radiation exposure but also incidental findings that warrant further workup. Cam Berg sits with Miz and MIke to discuss the real purpose of PE diagnosis and therapy; The importance of pre-diagnostic risk stratification; The strength of D-dimer testing; The weaknesses and limitations of CT scans and risk stratification and disposition of confirmed PE.

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Ian L., Dr -

If you had a malignancy within the last 6 months you will score only one point on the Wells Score for PE and unless malignancy is embedded in your clinical acumen for thrombosis that will be PERC negative even if a patient gets bouts of being short of breathe.
I have seen a 70 year old lady with recently treated breast cancer who I sent to ED with bouts of Dyspnoe diagnosed as anxiety due to her breast cancer diagnosis .
Fortunately after a short time pulmonary embolism was thought of and she was anticoagulated .
How often does this happen in USA series .

Mike W., MD -

Yes, I agree this is curious. I am glad you brought this up - we should always use these rules in the context of the patient's presentation - thx Ian!!

Angelina M. -

Is this accelerated pathway using the Wells' criteria for DVT or the Wells' criteria for PE? I could see using the DVT one because you are trying to figure out if they have a DVT as a cause of their PE and it has more criteria. However, I could also see using the PE one since you are evaluating the patient for a PE. If you use Wells' for PE then you get overlap with PERC in regards to heart rate, hemoptysis, surgery, prior dvt/pe. If you use Wells' for DVT with PERC then you get overlap of leg swelling, surgery, hx of dvt/pe. Thanks for the clarification!

Lisa Z., PA-C -

If we don't have access to STAT d-dimer in our clinic, for moderate risk patients do we still have to refer out to ER?

Mike W., MD -

Yes. That is what I would recommend.

Angelina M. -

Is this accelerated pathway using the Wells' criteria for DVT or the Wells' criteria for PE? Thanks!

Mizuho M., DO -

Thanks Angelina, this segment is referring to WELL's Criteria for PE. However there is a great segment coming out in NOVEMBER on DVT workup with Well's for DVT. And to follow, since PE workup can be confusing, we just recorded with Salim Rezaie MD on clarification of PE workup, which will give you a simple algorithmic approach with clarification on use of Well's for PE, this will come out in January 2020. So standby!!! Thanks for listening! ~Miz

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ID Killers Full episode audio for MD edition 206:50 min - 97 MB - M4AHippo Urgent Care RAP - June 2019 Written Summary 405 KB - PDF

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