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.

scholarly journals Physician and Patient Beliefs and Preferences in Pulmonary Embolism and Deep Vein Thrombosis Testing in People with Cancer

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4265-4265
Author(s):  
Anna Tran ◽  
Kerstin De Wit ◽  
Darshana Seeburruth
Keyword(s):  
Pulmonary Embolism ◽  
Diagnostic Imaging ◽  
Cancer Patients ◽  
Evidence Based ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Low Threshold ◽  
Deep Vein ◽  
D Dimer

Abstract Introduction It is unclear whether evidence-based diagnostic protocols are followed when cancer patients are tested for venous thromboembolism (VTE). Evidence-based protocols reduce unnecessary diagnostic imaging, offer a patient-centered approach, and have the potential to standardize practice across medical specialties and settings. However, anecdote suggests that specialists who test people with cancer for VTE may prefer diagnostic imaging over clinical probability scoring and D-dimer testing. The aim of this study was to identify physician and patient knowledge, beliefs, values and preferences for VTE testing in cancer. This study was part of a program of research to set International Society of Thrombosis and Haemostasis standards for VTE testing in people with cancer. Methods This was an international qualitative interview study following COREQ guidelines. Semi-structured interviews with physicians and cancer patients were conducted via Zoom. We used purposive sampling to ensure inclusion of physicians from all specialties who test people with cancer for VTE, practicing across all continents. We invited people treated for cancer who had and did not have experience of VTE testing. We used grounded theory to create a conceptual framework which explains physician and patient values and preferences for VTE testing. Transcripts were coded by three researchers independently, who met to discuss their findings and agree on common codes. Researchers were a Thrombosis physician and two undergraduate students who ensured reflexivity was incorporated into their analysis. Results A total of 32 physicians and 6 cancer patients were invited to interview. Of those invited, 23 physicians and 6 patients across 6 continents completed an interview. Interviews lasted between 21 and 86 minutes. Our derived conceptual model can be seen in the attached Figure. Physicians reported a low threshold to test for VTE in people with cancer compared to those without cancer, because VTE was considered a fatal disease and highly prevalent in this patient population. Imaging was generally the only test used for VTE testing in cancer patients. Many participants relied on their Gestalt estimation of VTE probability when deciding whether to order imaging for pulmonary embolism or deep vein thrombosis. Most thought that low Wells score in combination with a negative D-dimer was not sufficiently sensitive to exclude VTE and anticipated the Wells score and D-dimer to be elevated. The Wells scores had poor face validity because they do not include cancer-specific variables and participants hoped to see a more nuanced formal score for VTE testing in cancer patients. Participants believed that their colleagues would support their diagnostic approach. Patients reported they were used to having tests and CT scans. Patients felt it was important for their physicians to prioritize testing for VTE. Patients had full trust and confidence in their physicians' testing decisions, particularly in decisions made by their oncologists. Conclusion Physicians have a low threshold to test people with cancer for VTE and tend not to use clinical probability assessment and D-dimer. Patients are comfortable having diagnostic imaging, feel VTE testing is important and have full trust in their physicians. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals Reducing ultrasound in diagnosing deep vein thrombosis by using clinical scores and D-dimer testing

2020 ◽  
Vol 7 (2) ◽  
pp. 332
Author(s):  
Nehad Abdou Zaid ◽  
Mahmoud S. El Desoky ◽  
Seham F. Attia
Keyword(s):  
Emergency Department ◽  
University Hospital ◽  
Group 13 ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
The Mean ◽  
Deep Vein ◽  
Work Up ◽  
D Dimer

Background: To reduce unnecessary venous ultrasound examination in cases suspected to have deep venous thrombosis (DVT) in emergency department by using D dimer and wells score. venous duplex is widely used to diagnose DVT increasing burden on ultrasound in overcrowded emergency department. Authors can decrease this burden by using clinical probability scores and D dimer.Methods: This is prospective study done on 50 consecutive patients suspected to have DVT represented to emergency department of   Menoufia University Hospital during the period from June 2018 to June 2019. Full history, physical examination, assessment of clinical probability score, d dimer level and results of venous duplex collection.Results: According to wells score, the majority of cases diagnosed as DVT were of high probability group 13(68.4%), 5 patients with moderate probability and only one patient with low probability was diagnosed as DVT. The mean of D dimer level in cases diagnosed as DVT is (4173.6±2173.1) and in cases without DVT is (927.4±1064.6). Using wells score and D dimer together, sensitivity is 100%, Specificity is 94%. PPV is 90%, and NPV is 100% in predicting DVT. All cases with negative d dimer and low risk probability do not have DVT.Conclusions: Based on this result, using wells score and d dimer level in early work up of patients suspected to have DVT will decrease overusing and cost of venous duplex.

scholarly journals The diagnosis of pulmonary embolism

2016 ◽  
Vol 71 (2) ◽  
Author(s):  
A. Celi ◽  
L. Marconi ◽  
L. Villari ◽  
A. Palla
Keyword(s):  
Pulmonary Embolism ◽  
Computer Tomography ◽  
Final Diagnosis ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Lung Scan ◽  
Revised Geneva Score ◽  
Clinical Rules ◽  
Deep Vein

The diagnosis of pulmonary embolism is challenging, and autoptic series have demonstrated that a high percentage of cases are not recognized ante-mortem. A number of predisposing factors, symptoms and signs associated with pulmonary embolism have been recognized, and should be used to raise the suspicion of the disease. These include immobilization, recent surgery, active cancer, previous thromboembolism, syncope, dyspnoea, chest pain, haemoptysis, signs of deep vein thrombosis, hypocarbic hypoxemia. Once pulmonary embolism is suspected, the clinical probability of the disease should be assessed; to this end, three clinical rules have been proposed and validated (the revised Geneva score, the Wells score and the PISA-PED score) while others await clinical validation. In case of low clinical probability, a negative a D-dimer test is sufficient to rule out the diagnosis, while if the clinical probability is high, or the Ddimer test is positive, further tests are necessary. Computer tomography angiography or perfusion lung scan are the imaging tests of choice, depending on local availability and experience. If the clinical probability and the results of the imaging test are concordant, a definitive diagnosis can be obtained; if the results are discordant, further testing is necessary. In particular, in the specific case of a small clot (i.e. segmental or subsegmental) incidentally recognized at a computer tomography obtained for other reasons in a patient without a clinical suspicion of pulmonary embolism, an occurrence whose frequency is rapidly increasing in clinical practice, a final diagnosis cannot be made without further confirmatory testing.

scholarly journals Wells and Geneva decision rules to predict pulmonary embolism: can we use them in Covid-19 patients?

2021 ◽  
Vol 22 (Supplement_3) ◽  
Author(s):  
BV Silva ◽  
C Jorge ◽  
J Rigueira ◽  
T Rodrigues ◽  
P Silverio Antonio ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Characteristic Curve ◽  
Area Under The Curve ◽  
Signs And Symptoms ◽  
Discriminatory Power ◽  
Average Score ◽  
Clinical Probability ◽  
Significant Difference ◽  
Wells Score ◽  
D Dimer

Abstract Funding Acknowledgements Type of funding sources: None. Introduction  Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA.  Purpose  To evaluate the accuracy of the Wells and Geneva scores to predict PE in patients with SARS-COV2 infection. Methods  Retrospective study of consecutive outpatients with SARS-COV2 infection proved by positive PCR who underwent CTPA due to suspected PE. The Wells and Geneva scores were calculated and the area under the curve (AUC) of the receiver operating characteristic curve was measured. Results  We enrolled 235 patients (61% males, mean age 69.10 ± 16.69 years) and the incidence of pulmonary embolism was 15% (35 patients). In patients with PE, emboli were located mainly in segmental arteries (60%) and bilaterally (46%). Patients with PE were older (mean age 75.06 ± 2.23 vs. 68.06 ± 1.21 years, p = 0.022), and did not differ in sex or risk factors for thromboembolic diseases from the non-PE group. Patients with PE had higher D-dimer levels (median 15.41 mg/dl, IQR 1.17 – 20.00) compared to patients without PE (median 5.99 mg/dl, IQR 0.47 – 2.82, p < 0.001).  There was no statically significant difference between the average Wells score in patients with PE and without PE (1.04 and 0.89 respectively, p = 0.733) and the AUC demonstrated that the Wells score had no discriminatory power (AUC = 0.52). Within patients with PE, 19 patients had a Wells score of zero. Regarding the Geneva score, there was also no difference between the average score in patients with and without PE (4.20 vs 3.93 respectively, p = 0.420). AUC for Geneva score was 0.54. Clinical probability combined with D-dimer measurement had a 100% sensitivity for both Wells and Geneva scores, but a specificity of 10% and 11%, respectively.  Conclusion  PE diagnosis may be challenging in patients with SARS-COV2 infection since both conditions may have similar signs and symptoms and may be associated with increased D-dimers. According to our results, traditional clinical prediction scores have little discriminatory power in these patients and a higher D-dimer cut-off should be considered to better select patients for CTPA to minimize radiation exposure and contrast-related complications in COVID-19 patients.

Performance of five D-dimer assays for the exclusion of symptomatic distal leg vein thrombosis

2012 ◽  
Vol 107 (02) ◽  
pp. 369-378 ◽  
Author(s):  
Jan Schwonberg ◽  
Carola Hecking ◽  
Marc Schindewolf ◽  
Dimitrios Zgouras ◽  
Susanne Lehmeyer ◽  
...  
Keyword(s):  
High Sensitivity ◽  
Diagnostic Value ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Deep Vein ◽  
Test Result ◽  
D Dimer ◽  
Rule Out ◽  
Compression Ultrasonography

SummaryThe diagnostic value of D-dimer (DD) in the exclusion of proximal deep-vein thrombosis (DVT) is well-established but is less well-known in the exclusion of distal (infrapopliteal) DVT. Therefore, we evaluated the diagnostic abilities of five DD assays (Vidas-DD, Liatest-DD, HemosIL-DD, HemosIL-DDHS, Innovance-DD) for excluding symptomatic proximal and distal leg DVT. A total of 243 outpatients whose symptoms were suggestive of DVT received complete compression ultrasonography (cCUS) of the symptomatic leg(s). The clinical probability of DVT (PTP) was assessed by Wells score. Thirty-eight proximal and 31 distal DVTs (17 tibial/fibular DVTs, 14 muscle DVTs) were diagnosed by cCUS. Although all assays showed high sensitivity for proximal DVT (range 97–100%), the sensitivity was poor for distal DVT (range 78–93%). None of the assays were individually able to rule out all DVTs as a stand-alone test (negative predictive value [NPV] 91–96%). However, a negative DD test result combined with a low PTP exhibited a NPV of 100% for all DVTs (including proximal, tibial/fibular, and muscle DVTs) with the HemosIL-DDHS and Innovance-DD. All proximal and tibial/fibular DVTs, but not all muscle DVTs, could be ruled out with this strategy using the Liatest-DD and Vidas-DD. The HemosIL-DD could not exclude distal leg DVT, even in combination with a low PTP. The combination of a negative DD with a low PTP showed a specificity of 32–35% for all DVTs. In conclusion, our study shows that when used in conjunction with a low PTP some DD assays are useful tools for the exclusion of distal leg DVT.

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 Wells’ Score in Diagnosis of Pulmonary Embolism in Patient with Thrombocytopenia: A Case Report

2019 ◽  
Vol 20 (3) ◽  
pp. 281-285
Author(s):  
Dragan Panic ◽  
Andreja Todorovic ◽  
Milica Stanojevic ◽  
Violeta Iric Cupic
Keyword(s):  
Pulmonary Embolism ◽  
Chest Pain ◽  
Acute Pulmonary Embolism ◽  
Pretest Probability ◽  
Clinical Prediction ◽  
Clinical Prediction Rules ◽  
Prediction Rules ◽  
Clinical Probability ◽  
Wells Score ◽  
D Dimer

Abstract Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging. A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

scholarly journals Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e022063 ◽  
Author(s):  
Tammy J Bungard ◽  
Bruce Ritchie ◽  
Jennifer Bolt ◽  
William M Semchuk
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Severity Index ◽  
Vein Thrombosis ◽  
Risk Patients ◽  
Acute Venous Thromboembolism ◽  
Record Review ◽  
Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

Pulmonary embolism in Bujumbura

2021 ◽  
Vol 25 (4) ◽  
pp. 298-305
Author(s):  
Eugène Ndirahisha ◽  
Thierry Sibomana ◽  
Joseph Nyandwi ◽  
Ramadhan Nyandwi ◽  
Sébastien Manirakiza ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Past History ◽  
Personal Data ◽  
Minor Bleeding ◽  
Short Term ◽  
Clinical Probability ◽  
Medical Associations ◽  
Venous Thromboembolic ◽  
Wells Score ◽  
History Of

Relevance . Pulmonary embolism constitutes a diagnostic and therapeutic emergency. In Africa, data are still difficult to obtain. Thus, the objectives of this work is to describe epidemiological, clinical, therapeutic aspects and short-term outcomes of pulmonary embolism confirmed by thoracic angioscan at Kira hospital in Bujumbura, the biggest city of Burundi with population about 375 000. Patients and Methods . This was a descriptive study of 18 patients who had a pulmonary embolism confirmed by thoracic angioscan in Bujumbura from January 1st, 2015 to December 31st, 2018. We included in our study any patient with pulmonary embolism consenting to participate and processing personal data after some clarified explanations in accordance with the World Medical Associations Declaration of Helsinki. For each registered patient, we collected socio-demographic, past history of cardiac disease and factors risk, clinical, echocardiographic and scannographic findings with Wells score. Variables were presented as means and percentages. Results and Discussion. The average age was 53.5 12.3 years with a sex ratio of 1.25 in favor of women. The modal class was the 50 to 59 age group (33.3%). The clinical probability pre-test by simplified Wells score was high in 66.6% and medium in 33.3% of cases. A history of venous thromboembolic disease was the most common risk factor. Dyspnea was the most reason of consultation with 94.4% of cases. One patient died (5.6%) during hospitalization. Six months after discharge from the hospital, we recorded 3 cases (16.7%) of death, 6 cases (33.3%) of pulmonary heart, 3 cases (16.7%) of recurrent pulmonary embolism and one case of vitamin K antagonist overdose with minor bleeding. Conclusion. Pulmonary embolism is common in relatively young population with a predominance of females and chronic no communicable diseases as risk factors. Examination of a patient with an angioscanner is a sensitive and specific clinical study of pulmonary embolism. The outcome is favorable under appropriate treatment in short term.

Diagnosis of acute pulmonary embolism and evolving imaging modalities

ESC CardioMed ◽  
2018 ◽  
pp. 2761-2766
Author(s):  
Helia Robert-Ebadi ◽  
Grégoire Le Gal ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Thoracic Imaging ◽  
Diagnostic Strategies ◽  
Computed Tomographic ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Venous Compression ◽  
Computed Tomographic Pulmonary Angiography ◽  
Deep Vein

Modern non-invasive diagnostic strategies for pulmonary embolism rely on the sequential use of clinical probability assessment, D-dimer measurement, and thoracic imaging tests. Planar ventilation/perfusion scintigraphy was the cornerstone test for the diagnosis of pulmonary embolism for more than two decades and has now been replaced by computed tomographic pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out pulmonary embolism and have been well validated in large prospective management outcome studies. Venous compression ultrasonography is the cornerstone test to diagnose deep vein thrombosis but is not mandatory for the diagnosis of pulmonary embolism when using multidetector CTPA.

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