scholarly journals LO30: Prevalence of pulmonary embolism among emergency department patients with syncope: a multicenter prospective cohort study

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S17-S17 ◽  
Author(s):  
V. Thiruganasambandamoorthy ◽  
M. L.A. Sivilotti ◽  
B. H. Rowe ◽  
A. D. McRae ◽  
M. Mukarram ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
The United States ◽  
Pulmonary Angiogram ◽  
Emergency Department Patients ◽  
Multicenter Prospective Cohort Study ◽  
Multicenter Prospective Cohort ◽  
D Dimer ◽  
Combined Data

Introduction: The prevalence of pulmonary embolism (PE) among patients with syncope is understudied. Based on a recent study with an exceptionally high PE prevalence, some advocate investigating all syncope patients for PE, including those with another clear cause for their syncope. We sought to evaluate the PE prevalence among emergency department (ED) patients with syncope. Methods: We combined data from two large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of investigations related to PE (i.e. D-dimer or ventilation-perfusion (VQ) scan, or computed tomography pulmonary angiogram (CTPA)), and 30-day adjudicated outcomes including diagnosis of PE, arrhythmia, myocardial infarction, serious hemorrhage and/or death. Results: Of the 9,091 patients (median age 66 years, 51.9% females, 39.1% hospitalized) with 30-day follow-up, 546 (6.0%) were investigated for PE: 278 (3.1%) had D-dimer, 39 (0.4%) had VQ and 347 (3.8%) patients had CTPA performed. 30-day outcomes included: 874 (9.6%) patients with any serious outcome; 0.9% deaths; and 818 (9.0%) patients with non-PE serious outcomes. Overall, 56 patients (prevalence 0.6%; 95% CI 0.5% 0.8%) were diagnosed with PE, including 8 (0.1%) of those admitted to hospital at the index presentation. Only 11 patients (0.1%) with a non-PE serious condition had a concomitant underlying PE identified. Conclusion: The prevalence of PE is very low among ED patients with syncope, including those hospitalized following syncope. While acknowledging syncope may be caused by an underlying PE, clinicians should be cautious against indiscriminate over-investigations for PE.

scholarly journals LO01: Prevalence of pulmonary embolism among Canadian emergency department patients with syncope: a multicenter prospective cohort study

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S27
Author(s):  
V. Thiruganasambandamoorthy ◽  
M. Sivilotti ◽  
A. McRae ◽  
M.A. Mukarram ◽  
S. Kim ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Cross Sectional Study ◽  
Study Cohort ◽  
Cross Sectional ◽  
Wells Score ◽  
Emergency Department Patients ◽  
Multicenter Prospective Cohort Study ◽  
Work Up ◽  
D Dimer

Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.

Prospective Study of the Diagnostic Accuracy of the Simplify D-dimer Assay for Pulmonary Embolism in Emergency Department Patients

CHEST Journal ◽  
2006 ◽  
Vol 129 (6) ◽  
pp. 1417-1423 ◽  
Author(s):  
Jeffrey A. Kline ◽  
Michael S. Runyon ◽  
William B. Webb ◽  
Alan E. Jones ◽  
Alice M. Mitchell
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Diagnostic Accuracy ◽  
Prospective Study ◽  
Emergency Department Patients ◽  
D Dimer

scholarly journals P104: Evaluating the use of the pulmonary embolism rule-out criteria in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S93-S94
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
P. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Signs And Symptoms ◽  
Ct Scanning ◽  
Pulmonary Angiogram ◽  
Ct Angiogram ◽  
D Dimer ◽  
Rule Out

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism

2003 ◽  
Vol 12 (1) ◽  
pp. 17-18
Author(s):  
K.L. Dunn ◽  
J.P. Wolf ◽  
D.M. Dorfman ◽  
P. Fitzpatrick ◽  
J.L. Baker ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Emergency Department Patients ◽  
D Dimer

scholarly journals LO47: Use of C-reactive protein can safely decrease the number of emergency department patients with sepsis who require blood cultures

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S44
Author(s):  
R. Stenstrom ◽  
J. Choi ◽  
E. Grafstein ◽  
T. Kawano ◽  
D. Sweet ◽  
...  
Keyword(s):  
Emergency Department ◽  
Blood Culture ◽  
Positive Blood Culture ◽  
False Positive ◽  
Blood Cultures ◽  
Low Risk ◽  
Reactive Protein ◽  
Emergency Department Patients ◽  
Multicenter Prospective Cohort Study ◽  
Multicenter Prospective Cohort

Introduction: Sepsis protocols call for the acquisition of blood cultures in septic emergency department (ED) patients.However, the criteria for blood cultures are vague, they are costly, only positive 8-12% of the time, with up to half of these being false positives. The objective of this study was to establish if positive blood cultures could be excluded in low-risk sepsis patients with levels of CRP below 20 ml/L. Methods: This was a multicenter prospective cohort study of 765 ED patients at St Paul’s and Mount St Joseph’s hospitals in Vancouver with sepsis (2 or more SIRS criteria and infection) and none of: immuncompromised, injection drug use, indwelling vascular device or septic shock (SBP<90 mmhg). Consecutive patients with sepsis had CRP and blood cultures obtained at the same time.OUTCOMES. True positive blood cultures, false positive blood cultures, positive blood cultures that changed patient management. True and false positive blood cultures were based on Infectious Disease Society of America Guidelines, and change in management was defined as change in type or length of antibiotic therapy and was blindly adjudicated by a medical microbiologist. Results: 765 ED patients with sepsis met inclusion criteria. Mean age was 48.3 years and 57% were male. Blood cultures were positive in 99/765 (12.9%) subjects, of which 19 were false positive (19.2%). CRP was >20 mg/L in 595/765 (77.8%) of patients. Of 170 subjects with a CRP<20 mg/L, 3 had a positive blood culture (1.8%; 95% CI 0.1%- 5%). Management was not changed in any patient with a positive blood culture and CRP level<20 mg/L. Of 19 subjects with a false positive blood culture, CRP was <20 mg/L for 6 (31.6%). Conclusion: In this cohort of low-risk sepsis patients, based on a CRP of <20 mg/L, acquisition of blood cultures could be safely avoided in 22.2% of patients, at significant savings to the health care system.

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