scholarly journals The Use of Bedside Ultrasound in the Evaluation of Patients Presenting with Signs and Symptoms of Pulmonary Embolism

2013 ◽  
Vol 2013 ◽  
pp. 1-3
Author(s):  
Adarsh N. Patel ◽  
L. Connor Nickels ◽  
F. Eike Flach ◽  
Giuliano De Portu ◽  
Latha Ganti
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Radiation Exposure ◽  
Computerized Tomography ◽  
Signs And Symptoms ◽  
Pregnant Patient ◽  
Poor Quality ◽  
Pulmonary Angiography ◽  
Bedside Ultrasound

Evaluation of patients that present to the emergency department with concerns for the diagnosis of pulmonary embolism can be difficult. Modalities including computerized tomography (CT) of the chest, pulmonary angiography, and ventilation perfusion scans can expose patients to large quantities of radiation especially if the study has to be repeated due to poor quality. This is particularly a concern in the pregnant population that has an increased incidence of pulmonary embolism and may not be able to undergo multiple radiographic studies due to fetal radiation exposure. This paper presents a case of a pregnant patient with signs and symptoms concerning pulmonary embolism. The paper discusses the use of bedside ultrasound in the evaluation of patients with pulmonary embolism.

scholarly journals Information technology tools can automate imaging measures for Emergency Department patients with suspected pulmonary embolism

2019 ◽  
Author(s):  
Vlad I Valtchinov ◽  
Ivan Ip ◽  
Ramin Khorasani ◽  
Laila Cochon ◽  
Ronilda Lacson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Chest Pain ◽  
Language Processing ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Audit And Feedback ◽  
Pleuritic Chest Pain ◽  
Suspected Pulmonary Embolism ◽  
Ed Visits

Abstract CT pulmonary angiography (CTPA) utilization rates for patients with suspected pulmonary embolism (PE) in the Emergency Department (ED) have increased steadily with associated radiation exposure, costs and overdiagnosis. A new measure is needed to more precisely assess efficiency of CTPA utilization normalized to numbers of patients presenting with suspected PE, based on patient signs and symptoms. This study used natural language processing (NLP) to develop, automate, and validate SPE (“Suspected Pulmonary Embolism [PE]”), a measure determining CTPA utilization in ED patients with suspected PE. This retrospective study was conducted 4/1/2013-3/31/2014 in a Level-1 ED. A NLP engine processed “Chief Complaint” sections of ED documentation, identifying patients with PE-suggestive symptoms based on four Concept Unique Identifiers (CUIs: shortness of breath, chest pain, pleuritic chest pain, anterior pleuritic chest pain). SPE was defined as proportion of ED visits for patients with potential PE undergoing CTPA. Manual reviews determined specificity, sensitivity and negative predictive value (NPV). Among 5,768 ED visits with 1+SPE CUI, and 795 CTPAs performed, SPE=13.8% (795/5,768). NLP identified patients with relevant CUIs with specificity=0.94 [95%CI (0.89-0.96)]; sensitivity=0.73 [95%CI (0.45-0.92)]; NPV=0.98. Using NLP on ED documentation can identify patients with suspected PE to computate a more clinically-relevant CTPA measure. This measure might then be used in an audit-and-feedback process to increase the appropriateness of imaging of patients with suspected PE in the ED.

scholarly journals A visualized pulmonary arterial thrombus by using a new  echocardiographic view in an intermediate-risk a cute pulmonary embolism  patient: a case report

2019 ◽  
Author(s):  
Guanyu Mu ◽  
Feixue Li ◽  
Xiaolin Chen ◽  
Bo Zhao ◽  
Guangping Li ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Acute Pulmonary Embolism ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Normal Blood ◽  
Intermediate Risk ◽  
Normal Blood Pressure

Abstract BackgroundAcute pulmonary embolism (APE) is a life-threatening disease with nonspecific clinical signs and symptoms. Rapid and accurate diagnosis is crucial for the clinical management of patients with acute pulmonary embolism. A new recommended echocardiography view may be of further help in the diagnosis, evaluate the change of the thrombosis and treatment effect.Case presentationWe report a case of a 74-year-old man with a 12-day history of decreased exercise capacity and dyspnoea. The patient was diagnosed intermediate-risk APE as several pulmonary emboli in pulmonary artery were seen in multidetector computed tomographic pulmonary angiography with normal blood pressure and echocardiographic right ventricular overload. And we found a pulmonary artery clot in the right pulmonary artery through transthoracic echocardiography. After 11-days anticoagulation, the patient underwent a reassessment, showed decrease in RV diameter and pulmonary artery thrombus. ConclusionThis case highlights the significant role that echocardiography played in a patient who presented pulmonary embolism with a stable hemodynamic situation and normal blood pressure. The new echocardiographic view could provide correct diagnoses by identifying the clot size and location visually. Knowledge of the echocardiography results of APE would aid the diagnosis.

scholarly journals Feasibility and Efficacy of a Decision Aid for Emergency Department Patients with Suspected Ureterolithiasis: Protocol for an Adaptive Randomized Controlled Trial

2021 ◽  
Author(s):  
Elizabeth M Schoenfeld ◽  
Kye E Poronsky ◽  
Lauren M Westafer ◽  
Paul Visintainer ◽  
Brianna M DiFronzo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Randomized Controlled Trial ◽  
Ct Scan ◽  
Radiation Exposure ◽  
Kidney Stone ◽  
Decision Aid ◽  
Controlled Trial ◽  
Signs And Symptoms ◽  
Patient Knowledge ◽  
Randomized Controlled

Abstract Background: Approximately 2 million patients present to Emergency Departments in the US annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization. Methods: This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention – a decision aid (“Kidney Stone Choice”) – on patient-centered outcomes, compared with usual care. Patients age 18-55 presenting to the Emergency Department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization. Discussion: We hypothesize that this study will demonstrate that “Kidney Stone Choice,” the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy. Trial registration: ClinicalTrials.gov - NCT04234035https://clinicaltrials.gov/ct2/show/NCT04234035Registered January 21, 2020 – Retrospectively Registered

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.

scholarly journals Acute Pulmonary Embolism in Coronavirus Disease 2019

2020 ◽  
Author(s):  
Yanan Guo ◽  
Wenwu Sun ◽  
Yanli Liu ◽  
Yanling Lv ◽  
Su Zhao ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Manifestations ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Severe Condition ◽  
Computed Tomographic ◽  
Number Of Patients ◽  
Wells Score ◽  
Computed Tomographic Pulmonary Angiography ◽  
D Dimer

Abstract Background Pulmonary embolism is a severe condition prone to misdiagnosis given its nonspecific signs and symptoms. Previous studies on the pneumonia outbreak caused by coronavirus disease 2019 (COVID-19) showed a number of patients with elevated d-dimer, whether those patients combined with pulmonary embolism got our attention. Methods Data on clinical manifestations, laboratory and radiological findings, treatment, and disease progression of 19 patients with laboratory-confirmed COVID-19 pneumonia,who completed computed tomographic pulmonary angiography (CTPA) during hospitalization in the Central Hospital of Wuhan from January 2 to March 26, 2020, were reviewed. Results Of the 19 suspected pulmonary embolism and subjected to CTPA patients, six were diagnosed with pulmonary embolism. The Wells’ score of the six patients with pulmonary embolism was 0–1, which suggested a low risk of pulmonary embolism. The median level of d-dimers collected at the day before or on the day of CTPA completion in the patients with pulmonary embolism was 18.36 (interquartile range [IQR]: 6.69–61.46) µg/mL, which was much higher than that in the patients without pulmonary embolism (median 9.47 [IQR: 4.22–28.02] µg/mL). Of the 6 patients diagnosed with pulmonary embolism, all patients received anticoagulant therapy, 5 of which survived and were discharged and 1 died. Conclusion A potential causal relationship exists between COVID-19 infection and pulmonary embolism, but whether this phenomenon is common remains uncertain. The clinical manifestations of COVID-19 patients who developed pulmonary embolism are similar to those of patients with increased d-dimer alone, prompting a significant challenge on differential diagnoses.

scholarly journals Retrospective validation of a new volumetric capnography parameter for the exclusion of pulmonary embolism at the emergency department

2018 ◽  
Vol 4 (4) ◽  
pp. 00099-2018
Author(s):  
Timon M. Fabius ◽  
Michiel M.M. Eijsvogel ◽  
Marjolein G.J. Brusse-Keizer ◽  
Olivier M. Sanchez ◽  
Franck Verschuren ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Emergency Department ◽  
Pulmonary Embolism ◽  
Diagnostic Accuracy ◽  
Roc Curve ◽  
Predictive Value ◽  
Area Under The Curve ◽  
Carbon Dioxide Production ◽  
Pulmonary Angiography ◽  
Volumetric Capnography

Volumetric capnography might be used to exclude pulmonary embolism (PE) without the need for computed tomography pulmonary angiography. In a pilot study, a new parameter (CapNoPE) combining the amount of carbon dioxide exhaled per breath (carbon dioxide production (VCO2)), the slope of phase 3 of the volumetric capnogram (slope 3) and respiratory rate (RR) showed promising diagnostic accuracy (where CapNoPE=(VCO2×slope 3)/RR).To retrospectively validate CapNoPE for the exclusion of PE, the volumetric capnograms of 205 subjects (68 with PE) were analysed, based on a large multicentre dataset of volumetric capnograms from subjects with suspected PE at the emergency department. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and diagnostic accuracy of the in-pilot established threshold (1.90 Pa·min) were calculated. CapNoPE was 1.56±0.97 Pa·min in subjects with PE versus 2.51±1.67 Pa·min in those without PE (p<0.001). The AUC of the ROC curve was 0.714 (95% CI 0.64–0.79). For the cut-off of ≥1.90 Pa·min, sensitivity was 64.7%, specificity was 59.9%, the negative predictive value was 77.4% and the positive predictive value was 44.4%.The CapNoPE parameter is decreased in patients with PE but its diagnostic accuracy seems too low to use in clinical practice.

scholarly journals Feasibility and efficacy of a decision aid for emergency department patients with suspected ureterolithiasis: protocol for an adaptive randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Elizabeth M. Schoenfeld ◽  
Kye E. Poronsky ◽  
Lauren M. Westafer ◽  
Brianna M. DiFronzo ◽  
Paul Visintainer ◽  
...  
Keyword(s):  
Emergency Department ◽  
Randomized Controlled Trial ◽  
Ct Scan ◽  
Radiation Exposure ◽  
Kidney Stone ◽  
Decision Aid ◽  
Controlled Trial ◽  
Signs And Symptoms ◽  
Patient Knowledge ◽  
Randomized Controlled

Abstract Background Approximately 2 million patients present to emergency departments in the USA annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization. Methods This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention—a decision aid (“Kidney Stone Choice”)—on patient-centered outcomes, compared with usual care. Patients age 18–55 presenting to the emergency department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization. Discussion We hypothesize that this study will demonstrate that “Kidney Stone Choice,” the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy. Trial registration ClinicalTrials.gov NCT04234035. Registered on 21 January 2020 – Retrospectively Registered

scholarly journals The diagnostic pathway embolism: from the Emergency Department to the Internal Medicine Unit

2016 ◽  
Vol 10 (1) ◽  
pp. 4
Author(s):  
Attilia Maria Pizzini ◽  
Daniela Galimberti ◽  
Stefano De Pietri ◽  
Mauro Silingardi ◽  
Maria Cristina Leone ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Diagnostic Yield ◽  
Signs And Symptoms ◽  
Sudden Onset ◽  
Risk Scores ◽  
Vein Thrombosis ◽  
Diagnostic Pathway ◽  
Clinical Probability ◽  
Wells Score

The diagnostic pathway of pulmonary embolism, both in the Emergency Department and in the Medical Unit, is not a standardized one. Pulmonary embolism, often but not always complicating surgery, malignancies, different medical diseases, sometimes but not often associated with a deep vein thrombosis, is not infrequently a sudden onset life-threatening and rapidly fatal clinical condition. Most of the deaths due to pulmonary embolism occur at presentation or during the first days after admission; it is therefore of vital importance that pulmonary embolism should promptly be diagnosed and treated in order to avoid unexpected deaths; a correct risk stratification should also be made for choosing the most appropriate therapeutic options. We review the tools we dispose of for a correct clinical assessment, the existing risk scores, the advantages and limits of available diagnostic instruments. As for clinical presentation we remind the great variability of pulmonary embolism signs and symptoms and underline the importance of obtaining clinical probability scores before making requests for further diagnostic tests, in particular for pulmonary computer tomography; the Wells score is the only in-hospital validated one, but unfortunately is still largely underused. We describe our experience in two different periods of time and clinical settings in the initial evaluation of a suspected pulmonary embolism; in the first one we availed ourselves of a computerized support based on Wells score, in the second one we did not. Analysing the results we obtained in terms of diagnostic yield in these two periods, we observed that the computerized support system significantly improved our pulmonary embolism diagnostic accuracy.

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