Ambulatory PE: A walk in the park? St.Emlyn’s

 

What’s your weapon of choice then???

There have been a lot of developments within the last 10 years regarding our clinical approach to the patient with suspected pulmonary embolism. Arguably, there has been a lot of overall improvement. Emergency physicians on the whole seem to have a higher index of suspicion for the disease, access to definitive investigation has improved and there is a greater cross specialty understanding of the limitations in clinical examination. Much of this is due to robust original research from Emergency Physicians.

And the really great thing, is that no-one is resting on their laurels. New studies continue to be published in high impact journals regarding diagnostic tweaks, oral anticoagulants and prognostic scoring systems. We all continue to push for prompt effective diagnosis and safe therapy.

Lumping all of this great work together is tricky though. Therapeutic care bundles are everywhere these days, but people seem to be less inclined to collate individual aspects of diagnostic practice in a coherent approach. And probably for good reason. It is tricky to say with any scientific certainty that 2 well validated individual aspects of a diagnostic process will provide cumulative synergistic benefit when added together, unless they are studied together as a process. There are many authors that believe this type of diagnostic RCT to be the way forward for pragmatic research.

However, until these trials are completed we are left with multiple weapons in our diagnostic arsenal. It is left to us as clinicians to decide whether a scattergun approach is best or whether we prefer to stick to our single weapon of choice. Like all weapons, each of our diagnostic tools will have its detractors and its supporters. But this can leave clinical practice in a very heterogenous state. For instance, when considering the patient with suspected PE:

Do you PERC?

And if you PERC positively, then do you Wells or just have a guess(talt)?

And if you Wells negatively, then do you age adjust your d-dimer?

And if you Wells or age adjust your d-dimer positively, then do you risk stratify for outpatient versus inpatient CTPA?

And if you CTPA positively, then do you limit your treatment based on the isolation and segmentation of said embolus?

And if you CTPA positively, do you PESI to help you decide on outpatient management?

And if you outpatient manage, do you NOAC or VKA?

Or do you just DO IT ALL

Etc….

Putting it all together is hard. Which is why we all do it differently. But perhaps we shouldn’t. If we got our heads together to decide on a coherent management strategy of the patient with suspected disease, right from the word go, then perhaps we could follow that large cohort to get a good idea about whether firing all these individual weapons in the same direction was the right thing for the patient. And, dare I say it, whether it was cost effective.

Perhaps all this is why the British Thoracic Society has recently convened a guideline group to produce a document on the ambulatory management of suspected PE. There is a lot of new work to look at here and graded evidence based recommendations may help us all to sing from the same hymm sheet.

The College of Emergency Medicine has been invited to contribute to this group as a stakeholder; as such myself and others are off to London to throw our two pence worth into the ring. But our two pence is your two pence. I would love to hear from anyone who already runs an ambulatory pathway about the trials and tribulations, so I can take down additional real world experience to the group. Likewise if you don’t have a pathway or have real issues with some of the newer literature concerning diagnostics and therapeutics in pulmonary embolism, then let me know.  I will do my best to make sure your particular concerns or clinical questions are aired.

In the meantime – tool up and stick to your weapon/s of choice. But have a look at the references above and just consider whether it is time to pimp up your diagnostic arsenal. Just a little bit.

 

Dan

Posted by Dan Horner

Dr Daniel Horner BA MBBS MD PgCert MRCP (UK) FRCEM FFICM is an editorial board member on the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine of the Royal College of Emergency Medicine. He is a consultant in Emergency Medicine and Intensive Care at Salford Royal NHS Foundation Trust. He is chair of the national exemplar centre Thrombosis Committee and Regional lead for Injuries and Emergencies on the NIHR Clinical Research Network. He is a Senior clinical lecturer at the University of Manchester and collaborator with the University of Sheffield. You can find him on twitter as @RCEMProf

  1. MOPPETT and “safe dose thrombolysis” in selected patients, for me, a potential game changer , given the impact of Pulmonary HT down the track. There are several lines as you say, do we treat at all, and then down the path a bit to the bigger ones, do we thrombolyse and at what point does that thrombolysis become full strength (probably the easier decision). Best of luck with the meeting .

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  2. Don’t you Wells/Gestalt to see if you can even apply PERC? And don’t even mention the Green Top guidelines….Nice little reminder of why I have my medical calculator apps to hand on the shop floor and why CEM wants us involved in all patients discharged with non-traumatic chest pain.

    Fly the flag for us!

    Tom

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  3. Is anyone actually using age-adjusted D-dimer yet officially. I have just been having a discussion with our hematologists who are not keen as NICE doesn’t recommend.

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Thanks so much for following. Viva la #FOAMed

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