Workup question

[ShinyDome19]

So, I am a IM resident. I had a patient come in over the weekend evening from a Nursing Home. 95 yo F. Had a recent stroke <1-month ago, prior to which the pt was functional per records. So, the pt "Was found down in the Nursing Home, non-responsive and "guppy" breathing", was the only sign out that I received from the ER resident, as that was all he got from EMS when they arrived. No paper work or anything. Pt had an oxygen requirement of about 2L NC, prior to this event she had none. ER resident got a UA/BMP/CBC and called me for admission.
So, my differential just from that was very high suspicion for PE. However, I figured that even if it came back positive, I wouldn't be able to do anything for the patient really. The pt's UA came back dirty, high WBCs/Mucus/Bacteria. So, I opted to treat the patient for the UTI in hopes that the majority of her AMS was secondary to UTI. CBC showed WBC of ~13.
Exam on the patient, other than being elderly and looking pale as can be, was pretty benign. Breath sounds were CTA bilaterally.
So, the next day comes around and I present the patient to the attending and she just goes on an on about how bad it was that I didnt scan the patient for a PE. I told the attending my justification was that even if it did come back positive for PE, I wouldn't be able to anticoagulate the patient, and it just added fuel to the fire. At the end of the month review of my work, my attending just went back to that one case and harped on it again and never really gave me a good reasoning as to why I was wrong.

Just curious if anyone would have done the CT-PE and why? Is there something I am missing.

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[mimelim]

I must be missing something. Systemic/CD thrombolysis is contraindicated, but anti-coagulation certainly is not unless the stroke was hemorrhagic. Even if anti-coagulation was contra-indicated, an IVC filter can be placed to stop a second hit. I would have gotten an echo as well, or at least evaluated the heart by ultrasound myself to look for right heart dysfunction. The patient could have easily had a sub-massive PE and there certainly are things that could have been done for them in a well equipped hospital. If the hospital can not offer those other options, it behooves them to transfer to a hospital that can.

I'm not advocating going balls to the wall in a 95yo patient. But, I think that it is a pretty big miss if PE is high on one's differential to not image them despite having therapeutic options available. The problem is that you have no idea the extent of PE or where the clot is or anything (or if you should be looking for something else). What are the chances of hemorrhagic conversion of a 3 week old stroke vs. mortality of an untreated PE? Maybe things are different because we see and manage and treat a lot of PEs, but I'd be pretty pissed if I came in in the morning and an intern missed this and would consider it a patient safety issue and major deviation from standard protocol. There are a long list of treatments for PE and many of them were likely available for this patient, even beyond anti-coagulation. While YOU may not have been able to treat this patient, others with more expertise could have for sure and that to me is why not getting a CT-PE is a bad miss.

 

[Bacchus]

I would have seen the patient, got the history, and then called my on-call attending with assessment and plan. This doesn't warrant the same approach as "no need to call" for a 35 yo, normal BMI, no risk-factor-patient admitted with "CP" for ACS r/o.

Do you not routinely call your attendings with the admissions?

 

[Raryn]

So, I am a IM resident. I had a patient come in over the weekend evening from a Nursing Home. 95 yo F. Had a recent stroke <1-month ago, prior to which the pt was functional per records. So, the pt "Was found down in the Nursing Home, non-responsive and "guppy" breathing", was the only sign out that I received from the ER resident, as that was all he got from EMS when they arrived. No paper work or anything. Pt had an oxygen requirement of about 2L NC, prior to this event she had none. ER resident got a UA/BMP/CBC and called me for admission.
So, my differential just from that was very high suspicion for PE. However, I figured that even if it came back positive, I wouldn't be able to do anything for the patient really. The pt's UA came back dirty, high WBCs/Mucus/Bacteria. So, I opted to treat the patient for the UTI in hopes that the majority of her AMS was secondary to UTI. CBC showed WBC of ~13.
Exam on the patient, other than being elderly and looking pale as can be, was pretty benign. Breath sounds were CTA bilaterally.
So, the next day comes around and I present the patient to the attending and she just goes on an on about how bad it was that I didnt scan the patient for a PE. I told the attending my justification was that even if it did come back positive for PE, I wouldn't be able to anticoagulate the patient, and it just added fuel to the fire. At the end of the month review of my work, my attending just went back to that one case and harped on it again and never really gave me a good reasoning as to why I was wrong.

Just curious if anyone would have done the CT-PE and why? Is there something I am missing.

(If the patient's stroke was hemorrhagic, just ignore the below... but given that the majority are ischemic, that's what I'm assuming)

Depending on the size of the ischemic stroke, anticoagulation is relatively contraindicated... for up to a few weeks. If you truly suspected the patient had a PE, scanned them, and found one, unless it was an absolutely massive stroke (full hemisphere for example) or <2 weeks out, you'd be absolutely justified in heparinizing them. Even if they had the massive stroke and were <2 weeks out, you could make arguments both ways. In those cases, many people hedge and discuss the risks/benefits with neurology (or hematology) depending on your personal level of comfort.

So your decision was (probably) not 100% correct, but your attendings behavior definitely isn't right... they should explain to you why they disagree so you can learn from the mistake, not just ream you out over it on some eval.

Just an additional note re: PE treatment: While in this patient heparin is (probably) not contraindicated, TPA is absolutely contraindicated in recent stroke patients. If the patient was admitted with a (theoretical) massive PE, hypotension, hypoxemia not responsive to external O2, etc... Well, I'd probably talk about goals of care with the family. But if they wanted everything done and you can't give TPA, your only option at that point is to consult IR vs CT surgery for thrombectomy. But that's not the case you have anyway

 

[Bacchus]

I think "guppy" breathing is enough of a respiratory distress to warrant imaging in of itself.

 

[Bacchus]

One more post...

I'm surprised the ED didn't do a CTH and CTCh given the history. Boggles my mind. But then again, our ED has no problem pan CT'ing patients and exposing them to 20 equivalent years of radiation

 

[Trauma Surgeon]

To OP, you should have asked/discussed your plan with the senior/attending, then you wouldn't have to post this thread!
Unlike your attending, I would have probably suggested that you hold on the CT scan, if the nursing home does not insure me this is a highly functional 95y female (for her age). I see this often when nursing homes send in old dement patients, where the intern does a CT and it shows free air or suspect malignancy with secondary SBO/coloninc obstruction, and then I have to make the decision if the patient will benefit from a ex.lap!
Question: if the patients was still alive in the morning and the attending did not agree with your plan, I'm sure a CT was ordered. What did it show? What treatment did the patient receive? Outcome?

 

[Bacchus]

You may want to look at this OP:

DVT incidence= 40% in 1st 3 weeks of stroke, most develop in 1st week.
Risk factors: older age, severity of paralysis, and dehydration
Untreated DVT 15% risk of PE, an important early cause of death in stroke
Most fatal PE occur between weeks 2-4 after stroke

http://www.healthaffairs.uci.edu/nursing/docs/stoke-conference/post-stroke-complications.pdf

For future reference

 

[Trauma Surgeon]

You may want to look at this OP:

DVT incidence= 40% in 1st 3 weeks of stroke, most develop in 1st week.
Risk factors: older age, severity of paralysis, and dehydration
Untreated DVT 15% risk of PE, an important early cause of death in stroke
Most fatal PE occur between weeks 2-4 after stroke

http://www.healthaffairs.uci.edu/nursing/docs/stoke-conference/post-stroke-complications.pdf

For future reference

Bacchus, if I read OP's post correctly, he did not miss the diagnosis or didn't know the treatment of PE. He just did a conscious decision not to order the CT since he had already made up his mind not to treat the patient.

 

[Bacchus]

I see that now. Still a good refresher.

 

[ThoracicGuy]

(If the patient's stroke was hemorrhagic, just ignore the below... but given that the majority are ischemic, that's what I'm assuming)

Depending on the size of the ischemic stroke, anticoagulation is relatively contraindicated... for up to a few weeks. If you truly suspected the patient had a PE, scanned them, and found one, unless it was an absolutely massive stroke (full hemisphere for example) or <2 weeks out, you'd be absolutely justified in heparinizing them. Even if they had the massive stroke and were <2 weeks out, you could make arguments both ways. In those cases, many people hedge and discuss the risks/benefits with neurology (or hematology) depending on your personal level of comfort.

So your decision was (probably) not 100% correct, but your attendings behavior definitely isn't right... they should explain to you why they disagree so you can learn from the mistake, not just ream you out over it on some eval.

Just an additional note re: PE treatment: While in this patient heparin is (probably) not contraindicated, TPA is absolutely contraindicated in recent stroke patients. If the patient was admitted with a (theoretical) massive PE, hypotension, hypoxemia not responsive to external O2, etc... Well, I'd probably talk about goals of care with the family. But if they wanted everything done and you can't give TPA, your only option at that point is to consult IR vs CT surgery for thrombectomy. But that's not the case you have anyway

Just an FYI, but IR typically would only treat these with TPA infusions as well. For CT surgery, it would require full heparinization and going on bypass to do the thrombectomy. Both would have significant risks with a recent stroke and in a 95 year old, I'm not sure they would be viable options...

 

[ShinyDome19]

- I guess I should have explained better my Physical Exam on the patient. While she did have a new O2 requirement of 2L, she was breathing quite comfortably on my exam, definitely not "guppy" breathing. The patient was pale and emaciated. Turns out she hadn't really eaten anything since the stroke.
- At my program, we are not expected to call the attending's about every admission, only if we are uncomfortable with the admission - which hindsight is 20/20, I guess I should have. But, I really did not think that doing a CT on the pt would have changed my management at all.
- I did ask my attending about the problem with my plan and all I got was "you should have scanned this patient"; no real explanation even after having my end of month review with the attending, I still didn't get anything out of her.
- After some chart review, I found that the patient had recently fallen and fractured her arm; around the same time as the CVA, possibly with the same event. It was supposed to be in a sling, and it had not been the entire time at the NH. I also don't think she was getting any pain medications at the NH. Once I started her on some light pain medications, her mental status improved - she had a pretty significant deficit from the stroke however and definately wasn't going to do well overall as she couldn't swallow. Family had apparently opted against a PEG or NG tube or TPN during the stroke admission and sent her out hoping she would recover the ability to eat.
- CT-PE did show a small sub-segmental PE, which we did not end up doing anything for. I was actually able to wean the patient off O2 before rounds. But, we ended up just sending the patient out on hospice. The attending didn't want to do a Echo or LE Doppler. She did convince the family to place an IVC prior to putting the patient on hospice however.

 

[Doctor4Life1769]

I understand the OPs dilemma.
In this case, I would have discussed with the on call attending, and I have (I don't always call the attending, but for tricky stuff like this I would). I find a lot of times, attendings will go a little over board but in the end it is a CYA move on my part.

 

[mimelim]

Just an FYI, but IR typically would only treat these with TPA infusions as well. For CT surgery, it would require full heparinization and going on bypass to do the thrombectomy. Both would have significant risks with a recent stroke and in a 95 year old, I'm not sure they would be viable options...

There are a lot of other treatment modalities in the endovascular realm that don't involve tPA. Indigo, FlowTriever, Angiovac are all things that we use for submassive and massive PE treatment. Granted, we are a high volume PE center with a dedicated PE pager/team, but I think that it is wrong to not scan this patient. I described this case to my PD and he started railing on about "malpractice". tPA is contraindicated, putting a 95yo on bypass and doing open thrombectomy is insane. But, that isn't the point. The decision to not do tPA, endo thrombectomy, open thrombectomy, place an IVC filter, etc is not up to the IM resident on call at night. It is up to other specialties who should be involved early, which invariably will lead to a CT scan.

- I guess I should have explained better my Physical Exam on the patient. While she did have a new O2 requirement of 2L, she was breathing quite comfortably on my exam, definitely not "guppy" breathing. The patient was pale and emaciated. Turns out she hadn't really eaten anything since the stroke.
- At my program, we are not expected to call the attending's about every admission, only if we are uncomfortable with the admission - which hindsight is 20/20, I guess I should have. But, I really did not think that doing a CT on the pt would have changed my management at all.
- I did ask my attending about the problem with my plan and all I got was "you should have scanned this patient"; no real explanation even after having my end of month review with the attending, I still didn't get anything out of her.
- After some chart review, I found that the patient had recently fallen and fractured her arm; around the same time as the CVA, possibly with the same event. It was supposed to be in a sling, and it had not been the entire time at the NH. I also don't think she was getting any pain medications at the NH. Once I started her on some light pain medications, her mental status improved - she had a pretty significant deficit from the stroke however and definately wasn't going to do well overall as she couldn't swallow. Family had apparently opted against a PEG or NG tube or TPN during the stroke admission and sent her out hoping she would recover the ability to eat.
- CT-PE did show a small sub-segmental PE, which we did not end up doing anything for. I was actually able to wean the patient off O2 before rounds. But, we ended up just sending the patient out on hospice. The attending didn't want to do a Echo or LE Doppler. She did convince the family to place an IVC prior to putting the patient on hospice however.

I am still at a loss as to why you think that this patient couldn't a) Be put on anti-coagulation b) Get an IVC filter c) Get an endointervention. I take this a little personally because I have lost patients because of IM residents not ordering timely echos, late consults, and simply admitting a patient with a PE to the floor and not expeditiously treating them. It is one thing if the patient is already DNR or on hospice. But, unless that discussion has already happened, it is a pretty big mistake to not scan this patient and if you don't know how to manage this problem to send it up the ladder or consult someone who does. If you are comfortable with handling these issues at night by yourself, it is reasonable to have the hospice/DNR discussion right then and there, but otherwise, not scanning is asking for trouble.

Our PE team came about because of this exact situation. And please.... review the CHEST guidelines, especially if you think that you understand basic PE management and aren't calling your attendings.

 

[gracie369]

I know breath sounds were CTA but surprised the ED and you didn't get a CXR. Not everyone is a William Osler. You don't want to miss common things like pneumonia.

Wells score? Geneva score?

D-dimer. Not the best test but can rule out.

If you are really suspicious of a PE then scan. I've learned when in doubt usually do most tests as long as it's safe.

Stroke ischemic or hemorrhagic? Pretty sure you can anticoagulat if ischemic.

Was the UTI the source of the AMS? Did she get better?

 

[gracie369]

- CT-PE did show a small sub-segmental PE, which we did not end up doing anything for. I was actually able to wean the patient off O2 before rounds. But, we ended up just sending the patient out on hospice. The attending didn't want to do a Echo or LE Doppler.

Why would you do a LE doppler after you already know she has a PE. Also based on your history the PE seemed to be irrelevant. Pt is off oxygen, normal Vitals?, no AMS after UTI treatment?

 

[Raryn]

Just an FYI, but IR typically would only treat these with TPA infusions as well. For CT surgery, it would require full heparinization and going on bypass to do the thrombectomy. Both would have significant risks with a recent stroke and in a 95 year old, I'm not sure they would be viable options...

I've seen (mind you not in a 95 year old GOMER) people trialing catheter directed TPA when IV TPA was relatively contraindicated. Or if it's more central they can try to suck it out/rotorooter it (hell if I can keep track of the device names). But honestly, if this specific lady had a massive PE where thrombectomy was even a consideration (which she certainly didn't), I'd probably be having a frank discussion with the family regarding comfort measures before anything else.

That said, we don't have the whole case, but the OP clearly said that he thought PE was relatively high on his differential given the acuity of the presentation and the new oxygen requirement. I can imagine any IM resident has seen enough delerious UTIs to be able to pinpoint that there's just something off with how this one is presenting, given I have lots of old ladies that present in a similar fashion that I don't think need a scan. That, and the fact that the patient ended up actually having a PE means there was something off.

If there was indeed the gestalt that the patient might have a PE, which both the OP *and* his attending reportedly had, I still don't see any true contraindications to just scanning and heparinizing her when the scan comes back positive... ACCP and neurology guidelines both agree that depending on the stroke, it's almost certainly safe to give full dose anticoagulation 1-2 weeks later. Hell, if I remember right, it's as soon as 3 days with a small stroke.

You could consider the d-dimer, but any 95 year old, with or without a UTI, will have a borderline vs elevated d-dimer. I'd never order it on this lady personally, but there are some who would.

 

[mimelim]

Why would you do a LE doppler after you already know she has a PE. Also based on your history the PE seemed to be irrelevant. Pt is off oxygen, normal Vitals?, no AMS after UTI treatment?

Knowing clot burden is important in many/most patients. Lower Extremity duplex is very important, especially if you aren't going to be anti-coagulating. The first PE doesn't usually kill people that make it to the hospital alive. It is the second one that pushes them over the edge. You find that with a LE duplex.

 

[doc05]

I still can't figure out why PE was "high" on the differential. urosepsis alone will cause all of the above findings in a 95 year old. it's insane to do a PE study on everyone in that condition.

the only thing more insane is to put an IVC filter in a patient being sent to hospice.

 

[Bacchus]

Interesting discussion. All that said, the biggest thing that could have been done for this patient was never done.

1) Hospice consult with CVA admission
2) POLST
3) Never going back to the hospital

 

[Raryn]

I still can't figure out why PE was "high" on the differential. urosepsis alone will cause all of the above findings in a 95 year old. it's insane to do a PE study on everyone in that condition.

the only thing more insane is to put an IVC filter in a patient being sent to hospice.

That's why I said there has to be something more to the story. Clearly, the IM resident and the IM attending thought the patient might have a PE. Whether it's some (not offered) historical feature or just clinical gestalt, that's what matters. The resident just made the assumption that he didn't care whether the patient had a PE because for whatever reason she wouldn't be treated. That's his mistake, and it's a very different mistake than not getting the scan because you didn't think the patient had a PE (while the attending might have thought so for whatever reason).

All of the advice most of us are giving above is predicated on what to do in that situation where you have a patient like that who you think has a PE. What I'd do in a patient who I didn't think had a PE (which is the vast majority of old ladies found down/altered in nursing homes) is very different than if I think (for whatever reason) that they might have one.

 

[doc05]

That's why I said there has to be something more to the story. Clearly, the IM resident and the IM attending thought the patient might have a PE. Whether it's some (not offered) historical feature or just clinical gestalt, that's what matters. The resident just made the assumption that he didn't care whether the patient had a PE because for whatever reason she wouldn't be treated. That's his mistake, and it's a very different mistake than not getting the scan because you didn't think the patient had a PE (while the attending might have thought so for whatever reason).

All of the advice most of us are giving above is predicated on what to do in that situation where you have a patient like that who you think has a PE. What I'd do in a patient who I didn't think had a PE (which is the vast majority of old ladies found down/altered in nursing homes) is very different than if I think (for whatever reason) that they might have one.

yes, I agree there is something missing here. otherwise you'd be scanning every septic patient with a 2L oxygen requirement.

 

[Doctor4Life1769]

Interesting discussion. All that said, the biggest thing that could have been done for this patient was never done.

1) Hospice consult with CVA admission
2) POLST
3) Never going back to the hospital

What's polst?

 

[mimelim]

I still can't figure out why PE was "high" on the differential. urosepsis alone will cause all of the above findings in a 95 year old. it's insane to do a PE study on everyone in that condition.

the only thing more insane is to put an IVC filter in a patient being sent to hospice.

I'm not going to try to figure out what clinically made the resident/attending think "PE". Clinical decision making being what it is. My point here is simply that the reason for not ordering a CT-PE protocol should not be, "It won't change our management" if you don't know the management.

 

[Bacchus]

What's polst?

Physician Orders for Life Sustaining Treatment

Unlike an advance directive, it's an official order discussed between the patient and his or her physician. It prevents hospitalization, amongst other things, if against the patient's wishes. It's an official order such as your code status you order on admission.

Sections in PA's form include:
1) Resuscitation status
2) Full tx vs limited tx (such as IV abx at home) vs comfort treatment
3) Parenteral nutrition vs nothing vs a trial of parenteral feeding
4) IVF or no
5) Indicated a health proxy if patient is incapacitated

Unfortunately, right now, they're not always accepted across state boundaries.

The idea is, if EMS comes to your home and you have a POLST that says DNR they shouldn't do anything. The other things can be administered via home nurses or hospice.

 

[Doctor4Life1769]

Physician Orders for Life Sustaining Treatment

Unlike an advance directive, it's an official order discussed between the patient and his or her physician. It prevents hospitalization, amongst other things, if against the patient's wishes. It's an official order such as your code status you order on admission.

Sections in PA's form include:
1) Resuscitation status
2) Full tx vs limited tx (such as IV abx at home) vs comfort treatment
3) Parenteral nutrition vs nothing vs a trial of parenteral feeding
4) IVF or no
5) Indicated a health proxy if patient is incapacitated

Unfortunately, right now, they're not always accepted across state boundaries.

The idea is, if EMS comes to your home and you have a POLST that says DNR they shouldn't do anything. The other things can be administered via home nurses or hospice.

That is a nice plan.
I'm unsure if we have that where I am, because nobody's mentioned it and I certainly hadn't heard of the acronyms and needed clarification.

 

[Doctor4Life1769]

I'm not going to try to figure out what clinically made the resident/attending think "PE". Clinical decision making being what it is. My point here is simply that the reason for not ordering a CT-PE protocol should not be, "It won't change our management" if you don't know the management.

This is true. I think folks say "it won't change management" a tad too much at times.

 

[Bacchus]

This is true. I think folks say "it won't change management" a tad too much at times.

That's how I reason the 48h hold for MRIs on the stroke pathway sometimes

 

[gracie369]

Knowing clot burden is important in many/most patients. Lower Extremity duplex is very important, especially if you aren't going to be anti-coagulating. The first PE doesn't usually kill people that make it to the hospital alive. It is the second one that pushes them over the edge. You find that with a LE duplex.

It was actually a rhetorical question. I am talking about a pt with a PE needing anticoagulation just like the pt in this thread. There is no reason to do a LE Doppler to look for a DVT.

1. We do not dose lovenox/warfarin based on "clot burden". You won't say "that's a large clot I'm going to double your lovenox/inr." You won't say "we know you have a PE but we need to do a duplex to look for a clot and that will also tell us what dose of medication you will need"
2. What are the chances of a pt having a PE on full anticoagulation. Very slim.
3. What percentage of pts have PEs originating in the lungs? Close to zero. Most are from dvts.

I don't remember anything about assessing "clot burden" and how that will change management. Finding a DVT in a pt that will be anticoagulated for a PE will not change management.

I'm willing to be wrong if you have a paper or more info. I just don't remember that from any flow chart.

 

[mimelim]

It was actually a rhetorical question. I am talking about a pt with a PE needing anticoagulation just like the pt in this thread. There is no reason to do a LE Doppler to look for a DVT.

1. We do not dose lovenox/warfarin based on "clot burden". You won't say "that's a large clot I'm going to double your lovenox/inr." You won't say "we know you have a PE but we need to do a duplex to look for a clot and that will also tell us what dose of medication you will need"
2. What are the chances of a pt having a PE on full anticoagulation. Very slim.
3. What percentage of pts have PEs originating in the lungs? Close to zero. Most are from dvts.

I don't remember anything about assessing "clot burden" and how that will change management. Finding a DVT in a pt that will be anticoagulated for a PE will not change management.

I'm willing to be wrong if you have a paper or more info. I just don't remember that from any flow chart.

LE duplex do change management. Clot burden means where one has clot, not just quantity. If you have an iliofemoral DVT we are going to consider doing CDT or Angiovac, or several other endo options to avoid PTS. It is a standard part of PE workup. Certainly not something that must be done in the middle of the night, or something that will affect the outcome of the PE, but an important part of it. As you said correctly, most PEs come from the legs. If there is a large residual clot burden in the IVC, iliacs or femorals, it should be addressed and efficiently. Maybe not in this patient, but it is the standard part of PE protocols. I know, I spent 3 months visiting hospitals with dedicated PE teams to model ours after.

 

[ShinyDome19]

So, this has nothing to do with if I know how to manage a PE or not. I have managed many successfully over the years and we do not have some special team to call when we do have a suspected PE. I made a conscious decision while looking at my patient to treat the UTI as being the cause for the patient's symptoms, as doc05 mentioned, urosepsis can cause the same presentation for the most part, however I knew that PE was a very likely cause as well. I didn't "ignore" or "didn't care" about the fact that a PE could have occurred, however given the pt's history of recent CVA, which I did not know the type of CVA or date of, only that it had happened within the past month based on a note in the patient's chart for her fall which listed month and year for her CVA; the month was the current month. The date on the note for the fall/frx was just over 1-week, like literally 1-day over a week. About the only thing that was a viable option that I could think of while in the ER looking at this patient, was an IVC filter. However, that is not something I could have done without talking with family, which there wasn't any around.

The patient's vitals on presentation to the ER were fairly normal, aside from a heart rate that was in the high 90's.

For the most part, the ER resident and attending chose not to scan the patient as well, pretty much for the same reason I had. The next day, my attending agreed that we could not safely anticoagulate the patient, but still berated me for not getting the scan. Which, I honestly have no friggen clue as to what we would get out of scanning the patient once we all agree that were not going to anticoagulate, other than some talking points with the family and a pretty picture. Not to mention the risk of killing the patient's kidneys with a contrasted scan - given her kidney function wasn't horrible, as about to be expected for kidneys at are 95 years old, but honestly she probably would have tolerated the scan fine. Furthermore, given her AMS, would she have had to been sedated for a scan? very possibly. It actually made more sense to me to doppler the patient at that point, but even my attending opted against that.

The patient's Wells score, going off the top of my head, depending on what assumptions I make about the patient, put her into a category of low to Intermediate. She had no symptoms of DVT, she was tachycardic....was she ambulatory before this...from looking at her, probably not. I had thought about getting a D-dimer, however as someone already alluded to, I knew she had a pretty good UTI, and her age was through the roof - those two things alone would have resulted in a elevated DDimer. And, even if it came back elevated, I still didn't plan on scanning her. If it came back negative...yay I feel warm a fuzzy.
The patient's Geneva score, again off the top of my head, would have definitely been high risk.

Her mental status improved after starting treatment for UTI and giving pain medications for the fractured arm.

I appreciate all the input, this has turned in to a much better conversation than I expected.

 

[gracie369]

LE duplex do change management. Clot burden means where one has clot, not just quantity. If you have an iliofemoral DVT we are going to consider doing CDT or Angiovac, or several other endo options to avoid PTS. It is a standard part of PE workup. Certainly not something that must be done in the middle of the night, or something that will affect the outcome of the PE, but an important part of it. As you said correctly, most PEs come from the legs. If there is a large residual clot burden in the IVC, iliacs or femorals, it should be addressed and efficiently. Maybe not in this patient, but it is the standard part of PE protocols. I know, I spent 3 months visiting hospitals with dedicated PE teams to model ours after.

I personally agree with you. However it's not standard of care/protocol for most specialties including IM.

 

[gracie369]

I had thought about getting a D-dimer, however as someone already alluded to, I knew she had a pretty good UTI, and her age was through the roof - those two things alone would have resulted in a elevated DDimer. And, even if it came back elevated, I still didn't plan on scanning her.

For sick, inflamed, older pts use d-dimer to rule out not rule in. So a low/negative d-dimer with low/intermediate wells score likely not a PE. As you said, an elevated d-dimer doesn't really help.

 

[shoal]

For sick, inflamed, older pts use d-dimer to rule out not rule in. So a low/negative d-dimer with low/intermediate wells score likely not a PE. As you said, an elevated d-dimer doesn't really help.

Ddimer only has a npv of about 50percent. Only use it in low risk patients.... If she is mod or high risk I still need to scan

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[TooMuchResearch]

I'm not going to try to figure out what clinically made the resident/attending think "PE". Clinical decision making being what it is. My point here is simply that the reason for not ordering a CT-PE protocol should not be, "It won't change our management" if you don't know the management.

Most places aren't doing the interventions you mentioned.

I've specifically asked some of our pulm crit docs about them, and the response is "show me the data." We don't do that.

Assuming the other ~8 lab/imaging studies that I would have done were done, if PE remains high, sure work it up.

Your attending calling this malpractice suggests either your legal climate sucks or he/she does too much plaintiff consulting : /

 

[NotAProgDirector]

I think you'll find things like this are attending dependent. Given the details supplied, I might not order a CT PE. Not because we wouldn't do anything, but because it seems an unlikely explanation for the patient's problems. As pointed out, placing an IVC filter can (almost) always be done, so there is usually some option for treatment. Chances are the attending involved is upset not because of what you did, but because of why they think you did it -- if you transmitted the message "She's 95 and has had a stroke so who cares?", you could imagine that might cause some problems. You might not have meant that, but it might have come across that way.

I agree that, in this case, if the ultimate plan was hospice the filter was a waste. In addition, "1 subsegmental PE" is often an overread of a study (see: http://www.ajronline.org/doi/abs/10.2214/AJR.14.13938). So perhaps there really was nothing there at all.

Catheter based DVT treatment is very controversial. There is no good data, and lots of opinions.

 

[gracie369]

Ddimer only has a npv of about 50percent. Only use it in low risk patients.... If she is mod or high risk I still need to scan

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No and no. Maybe I just got tricked into doing your homework.

npv is much higher than 50%. It wouldn't be helpful at all if it was 50%

http://www.hindawi.com/journals/emi/2010/185453/
http://www.hindawi.com/journals/emi/2010/185453/tab1/

http://www.ncbi.nlm.nih.gov/pubmed/21847593
"D-dimer can be used to exclude acute pulmonary embolism (PE) for its high negative predictive value (NPV)."

For intermediate you get d-dimer first
Page 8
http://r.wildcatem.com/wp-content/u...li_Deep-Vein-Thrombsis_Pulmonary-Embolism.pdf

http://emedicine.medscape.com/article/1918940-overview#a1
"For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, use a high-sensitivity plasma D-dimer test as the initial test."

 

[shoal]

No and no. Maybe I just got tricked into doing your homework.

npv is much higher than 50%. It wouldn't be helpful at all if it was 50%

http://www.hindawi.com/journals/emi/2010/185453/
http://www.hindawi.com/journals/emi/2010/185453/tab1/

http://www.ncbi.nlm.nih.gov/pubmed/21847593
"D-dimer can be used to exclude acute pulmonary embolism (PE) for its high negative predictive value (NPV)."

For intermediate you get d-dimer first
Page 8
http://r.wildcatem.com/wp-content/u...li_Deep-Vein-Thrombsis_Pulmonary-Embolism.pdf

http://emedicine.medscape.com/article/1918940-overview#a1
"For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, use a high-sensitivity plasma D-dimer test as the initial test."

2 very poor studies. The first is prospective but based on people the ED would scan anyhow. Only 3 people got a ddimer which was negative then got a c.t. scan.

The second is looking at recurrence of dvt. I'm not sure how thsts generalizable to the population. None the less 50percent npv is too low, but it still isn't great in something that can kill you

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[gracie369]

2 very poor studies. The first is prospective but based on people the ED would scan anyhow. Only 3 people got a ddimer which was negative then got a c.t. scan.

The second is looking at recurrence of dvt. I'm not sure how thsts generalizable to the population. None the less 50percent npv is too low, but it still isn't great in something that can kill you

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You are arguing with facts and protocols that have been in place for 15 years. Not going to continue with someone who does not have a clue. Get a textbook and have a conversation with an attending about your ideas so they can help you.