a confused UW question- management of PE

[cliffh65]

This is the Explanation from UW about:

The management of pulmonary embolus (PE) in a Hemodynamically stable patient---

V/Q scan is the most helpful initial evaluation to rule out pulmonary embolus after chest x-ray, ABG and EKG are obtained.
But V/Q Scan is not necessarily done prior to the use of heparin, and so are other diagnostic tests. If you suspect a pulmonary embolism clinically, and chest X ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis.

My question: I highly doubt about this conclusion. Shouldn’t we always do a V/Q scan before starting heparin treatment?

Thank you for any input!!!

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[sdnetrocks]

(Just took CK yesterday...)

Most of the time, PE is not an easy diagnosis to make because the presentation is too soft, so we do the CXR, D-dimer, V/Q (which, at my institution, is most often "intermediate probability"), and finally PE-protocol CT...

However, if the patient presents with a CLASSIC history and has a FLORID PE, the benefits of immediately treating with heparin (if the pt doesn't have a PE) apparently outweigh the risks of first waiting for the V/Q scan... in THIS scenario only.

 

[RastaMan]

It all depends on pre-test probability of PE (look up Well's score which is as easy way to estimate pre-test probability of PE based on signs and symptoms).

High probability: Start anticoagulation before confirmatory testing (helical CT scan or V/Q scan).

Intermediate probability: Helical CT or V/Q scan before starting anticoagulation

Low probability: 1st get d-dimer --> CT or V/Q only if positive --> anticoagulate only if dx confirmed

 

[Idiopathic]

Totally agree with the above post. If you truly suspect PE (immobilized patient, tachycardic, dyspneic, low SpO2, recent surgery, older, etc) start heparin, then scan. If you only kind of suspect it (ICU patient, precautions in place, but still acutely tachycardic and dyspneic) you can scan first. Usually there will be a large difference between the patient presentation, at least for purposes of the test. You just have to determine how sick you think the test question patient is.

 

[Idiopathic]

(Just took CK yesterday...)

Most of the time, PE is not an easy diagnosis to make because the presentation is too soft, so we do the CXR, D-dimer, V/Q (which, at my institution, is most often "intermediate probability"), and finally PE-protocol CT...

However, if the patient presents with a CLASSIC history and has a FLORID PE, the benefits of immediately treating with heparin (if the pt doesn't have a PE) apparently outweigh the risks of first waiting for the V/Q scan... in THIS scenario only.

But remember, heparin doesnt get rid of the PE, only reduces the chance of recurrence. You wont help the patients PE symptoms with heparin, so thrombolytics is also a potential therapy.

 

[Idiopathic]

oops

 

[cliffh65]

Thanks guys.
Congratulations, sdnetrocks, you are done!!! Must be a good one.
RastaMan, Idiopathic, I agree with you.