An Emergency Department Guideline for the Diagnosis of Pulmonary Embolism: An Outcome Study

[Bronchial and nonbronchial systemic artery embolization in managing haemoptysis: 31 years of experience]

PURPOSE

The authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis.

MATERIALS AND METHODS

A total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded.

RESULTS

Complete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8-36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%).

CONCLUSIONS

BAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.

Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism

This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

High-risk chief complaints I: chest pain--the big three

Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism

OBJECTIVE

The goal of this study was to test the efficacy of clinical risk algorithms and a quantitative immunoturbidimetric D-dimer assay in the evaluation of patients undergoing pulmonary CT angiography for suspected acute pulmonary embolism.

SUBJECTS AND METHODS

From April 1, 2007, to March 31, 2008, emergency department evaluations for clinically suspected pulmonary embolism were performed with the revised Geneva score, a quantitative D-dimer assay, and pulmonary CT angiography.

RESULTS

Evaluations for pulmonary embolism were performed for 745 consecutively registered patients, 627 of whom were included in the study. The other 118 patients were excluded because a d-dimer assay was not performed. According to the revised Geneva score, 281 patients had low clinical probability of having pulmonary embolism; 330, intermediate probability; and 16, high probability. CT angiography showed that 28 patients had pulmonary embolism (six in the low-probability group, 17 in the intermediate-probability group, and five in the high-probability group). The sensitivity, negative predictive value, and specificity of the D-dimer assay were 100%, 100%, and 25% (low-clinical-probability group); 100%, 100%, and 33% (intermediate-probability group); and 80%, 80%, and 37% (high-probability group).

CONCLUSION

The data appear to support the use of a quantitative D-dimer assay as a first-line test in evaluation for pulmonary embolism when the clinical probability of the presence of pulmonary embolism is low or intermediate. The sensitivity and negative predictive value were 100% for these cases. More than 26% of CT angiographic examinations might have been avoided if the D-dimer assay had been used as a first-line test in the care of patients at low or intermediate risk. Because of the small sample size, the D-dimer assay is not recommended as a first-line test in the evaluation of patients at high risk.

Examination of hospital referral practices for CT pulmonary angiography

Guidelines for the evaluation of venous thromboembolism (VTE) include a history and physical examination in conjunction with computed tomographic pulmonary angiography (CTPA), Doppler ultrasonography, and D-dimer measurements. We performed a retrospective analysis to evaluate the diagnostic yield of CTPA at our facility. Patients between the ages of 18 and 100 with a CTPA completed through the emergency department and/or any inpatient service over a 6-month period were reviewed and a retrospective Simplified Wells Score was calculated. Three hundred and three patients underwent CTPA for acute VTE. A Simplified Wells Score was calculated for 279 subjects, with a mean score of 1.6 +/- 1.6. Twenty CTPA procedures demonstrated VTE, a positive rate of 7.2%, which was lower than expected. This result likely reflects lack of adherence to a clinical algorithm for assessment of VTE and an overly cautious approach to symptom evaluation.

Prospective study of the diagnostic accuracy of the simplify D-dimer assay for pulmonary embolism in emergency department patients

OBJECTIVE

To determine if a d-dimer assay (Simplify D-dimer; Agen Biomedical; Brisbane, Australia) can reliably exclude pulmonary embolism (PE) by producing a posttest probability of PE < 1% in low-risk, symptomatic emergency department (ED) patients.

METHODS

Hemodynamically stable patients were evaluated for PE using a structured d-dimer-centered protocol; d-dimer testing was performed prior to imaging. Prior to testing, physicians completed an electronic data form that included their unstructured clinical estimate for the pretest probability of PE (< 15%, 15 to 40%, or > 40%) and the elements of the Charlotte rule and Canadian score for PE. Criterion standard was selective use of pulmonary vascular imaging and 90-day follow-up.

RESULTS

We enrolled 2,302 patients (mean age, 45 +/- 16 years [+/- SD]; 31% male); 108 patients received a diagnosis of PE (4.7%; 95% confidence interval [CI], 3.6 to 5.6%). The overall sensitivity and specificity of the d-dimer assay were 80.6% (95% CI, 71.8 to 87.5%) and 72.5% (95% CI, 70.6 to 74.4%), respectively. The negative likelihood ratio and negative predictive value were 0.27 (95% CI, 0.18 to 0.39) and 98.7% (95% CI, 98.0 to 99.1%), respectively. The posttest prevalence of PE among low-risk patients with negative d-dimer results was 0.7% (95% CI, 0.3 to 1.4%) for the unstructured estimate, 1.2% (95% CI, 0.7 to 2.0%) for the Canadian score, and 1.1% (95% CI, 0.6 to 1.7%) for the Charlotte rule.

CONCLUSIONS

The Simplify D-dimer assay had moderate sensitivity and relatively high specificity for PE in low-risk ED patients. The combination of a physician's unstructured estimate of pretest probability of PE of < 15% and a negative d-dimer result produced a posttest probability of PE of 0.7% (95% CI, 0.3 to 1.4%).