British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism

CT venography for the diagnosis of postpartum venous thromboembolism: a prospective multi-center cohort study

OBJECTIVES

To assess the role of CT venography (CTV) in the diagnosis of venous thromboembolism (VTE) during the postpartum period.

MATERIALS AND METHODS

This multicenter prospective cohort study was conducted between April 2016 and April 2020 in 14 university hospitals. All women referred for CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) within the first 6 weeks postpartum were eligible. All CTPAs were performed on multidetector CT machines with the usual parameters and followed by CTV of the abdomen, pelvis, and proximal lower limbs. On-site reports were compared to expert consensus reading, and the added value of CTV was assessed for both.

RESULTS

The final study population consisted of 123 women. On-site CTPA reports mentioned PE in seven women (7/123, 5.7%), all confirmed following expert consensus reading, three involving proximal pulmonary arteries and four limited to distal arteries. Positive CTV was reported on-site in nine women, five of whom had negative and two indeterminate CTPAs, bringing the VTE detection rate to 11.4% (14/123) (95%CI: 6.4-18.4, p = 0.03). Expert consensus reading confirmed all positive on-site CTV results, but detected a periuterine vein thrombosis in an additional woman who had a negative CTPA, increasing the VTE detection rate to 12.2% (15/123) (95%CI: 7.0-19.3, p = 0.008). Follow-up at 3 months revealed no adverse events in this woman, who was left untreated. Median Dose-Length-Product was 117 mGy.cm for CTPA and 675 mGy.cm for CTPA + CTV.

CONCLUSION

Performing CTV in women suspected of postpartum PE doubles the detection of venous thromboembolism, at the cost of increased radiation exposure.

CLINICAL RELEVANCE STATEMENT

CTV can help in the decision-making process concerning curative anticoagulation in women with suspected postpartum PE, particularly those whose CTPA results are indeterminate or whose PE is limited to the subsegmental level.

KEY POINTS

Postpartum women are at risk of pulmonary embolism, and CT pulmonary angiography can give equivocal results. CT venography (CTV) positivity increased the venous thromboembolism detection rate from 5.7 to 11.4%. CTV may help clinical decision-making, especially in women with indeterminate CTPA results or subsegmental emboli.

The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study

PURPOSE

Echocardiography is recommended as a first-line tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. The aims of this work were to evaluate the utilisation of echocardiography in patients presenting to critical care with shock, its impact on decision making, and adherence to governance guidelines.

METHODS

We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom (UK) and Crown Dependencies, led by the UK's Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 h to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making.

RESULTS

1015 patients with shock were included. An echocardiogram was performed on 545 (54%) patients within 72 h and 436 (43%) within 24 h of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive or cardiogenic shock had their management altered numerically more often by echocardiography (n = 15 [75%] and n = 100 [58%] respectively). Twenty-five percent of echocardiograms performed adhered to current national governance and image storage guidance.

CONCLUSION

Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock.

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study

Background

Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity.

Objectives

Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein.

Methods

This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search.

Discussion

This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy

PURPOSE

Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy.

METHODS

The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE.

RESULTS

A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016.

CONCLUSIONS

Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.

Comparison of international guideline recommendations for the diagnosis of pulmonary embolism

Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.

Pulmonary embolism presenting as delirium: an acute confusional state in an elderly patient-a case report

Background

Large numbers of elderly patients are admitted to hospitals in acute confusional states. In many, the underlying causes are easily found; in some, correct diagnosis is difficult. Pulmonary embolism (PE), the most serious clinical presentation of venous thromboembolism, is often misdiagnosed because of its non-specific features including delirium.

Case presentation

A 73-year-old woman was admitted to our hospital in a confused state with no obvious risk factors of PE. D-dimer levels were elevated and contrast-enhanced high-resolution computed tomography (HRCT) of the chest confirmed the diagnosis of PE. She was treated with enoxaparin and discharged on dabigatran. Her symptoms had resolved at the time of discharge, and she has been stable for over three month's follow-up visit.

Conclusion

PE should be regarded as a differential in elderly patients with an acute confusional state despite the absence of obvious risk factors. Investigating for and treating when confirmed may save a life.

A 60-Year-Old Woman with a 6-Week History of Shortness of Breath and Intermittent Chest Pain Due to Chronic Thromboembolic Pulmonary Disease Undetected by Computed Tomography Pulmonary Angiography (CTPA) and Diagnosed by Ventilation-Perfusion Imaging

BACKGROUND Chronic thromboembolic pulmonary disease (CTEPD) is the persistent occlusion of pulmonary arteries resulting from 1 or more thrombo-emboli. Its presentation is often non-specific, with exertional dyspnea and fatigue, yet if left undiagnosed risks of chronic thromboembolic pulmonary hypertension and right-sided cardiac failure can ensue. Computed tomography pulmonary angiography (CTPA) and ventilation/perfusion (V/Q) imaging are most commonly utilized for investigating CTEPD. This report is of a 60-year-old woman with a 6-week history of breathlessness and intermittent chest pain due to CTEPD, undetected by CTPA and diagnosed by V/Q imaging. CASE REPORT A 60-year-old woman presented with a 6-week history of breathlessness, intermittent chest pain, and reduced mobility. Her past medical history included chronic obstructive pulmonary disease, pulmonary sarcoidosis, and obesity. Screening tests for infective and ischemic cardiac etiologies were unremarkable. A calculated Wells score was 6, making CTEPD the main differential diagnosis, and she was commenced on therapeutic dose anticoagulation. A CTPA performed on day 2 of admission showed no evidence of acute thromboembolic pulmonary disease or CTEPD. Instead, V/Q scintigraphy on day 6 revealed a perfusion mismatch in the right lung apex, consistent with CTEPD. The patient improved clinically and was discharged on long-term apixaban. CONCLUSIONS A negative CTPA does not necessarily exclude CTEPD. The sensitivity of CTPA for CTEPD is lower than that of V/Q imaging, and can hence lead to false-negative results, as this case highlights. When there is a high clinical suspicion for CTEPD but a negative CTPA study, V/Q imaging should always be undertaken.

Prediction of prognosis and outcome of patients with pulmonary embolism in the emergency department using early warning scores and qSOFA score

OBJECTIVE

To determine the prediction ability of the National Early Warning Score (NEWS), National Early Warning Score 2 (NEWS2), and quick Sequential Organ Failure Assessment (qSOFA) score for the prognosis of pulmonary embolism (PE) in the emergency department.

METHODS

This retrospective study involved 245 patients with PE. The NEWS, NEWS2, and qSOFA scores were compared according to the hospitalization clinic (ward vs. intensive care unit), hospitalization length (<10 vs. >10 days), severity of embolism (massive vs. submassive), and outcome (discharged vs. died).

RESULTS

The areas under the curve of the NEWS, NEWS2, and qSOFA score for 1-week mortality were 0.854 (sensitivity, 78%; specificity, 73%; cutoff, 7.5; confidence interval, 0.807-0.902), 0.870 (sensitivity, 83%; specificity, 73%; cutoff, 5.5; confidence interval, 0.825-0.915), and 0.789 (sensitivity, 83%; specificity, 51%; cutoff, 0.5; confidence interval, 0.720-0.858), respectively.

CONCLUSION

The NEWS2 more accurately predicts 1-week mortality than do the NEWS and qSOFA score in patients with PE.

Early Diagnosis of Pulmonary Embolism Related to Clinical Presentation and Vital Signs in the Emergency Department at King Saud Medical City

Background: Pulmonary embolism (PE) is a common acute life-threatening cardiovascular disorder. It is the third most common cause of hospital-related death and early detection and management of PE are crucial. The study aimed to evaluate the association between vital signs and laboratory investigations with PE.

Methods: This is a retrospective, hospital records-based, observational study, conducted among patients who were admitted to the emergency department of King Saud Medical City in Riyadh, Saudi Arabia with a suspected diagnosis of PE during the period of March 2021 to March 2022. Data were collected by searching patients’ files and recording demographic data, and information about the clinical presentation, workup, and outcome. Data were entered and analyzed using SPSS version 26 (IBM, Armonk, NY), utilizing Chi-square statistics to test differences between groups, and logistic regression analyses to identify predictors of PE.

Results: The study included 92 patients, with a preponderance of females (70.7%), and those aged 40-60 years (51.1%). Diabetes mellitus (44.6%), and hypertension (30.4%) were the most common comorbidities among others, while shortness of breath (SOB) (83.7%), and chest pain (44.6%) were among the most commonly reported symptoms. A majority of patients had tachycardia (64.1%), while about half had low oxygen saturation (51.5%), and nearly one-third had tachypnea (29.3%), which was more predominant among those not diagnosed with PE. Logistic regression analysis revealed that SOB, respiratory rate, and oxygen saturation were the only significant predictors of PE.

Conclusion: Although being an integral part of the initial assessment in the hospital, measuring the vital signs is not always reflective of the likelihood of PE, and they should not be the only metric relied upon to make decisions about treatment approaches in patients with PE. Physicians should ensure the employment of evidence-based clinical prediction rules and guidelines when diagnosing and managing PE.

Massive pulmonary embolism treated with low-dose thrombolysis on the geriatric ward during the COVID-19 pandemic

A man in his 70s was admitted to hospital due to a fall, urinary tract infection and delirium. The patient had a ‘do not attempt cardiopulmonary resuscitation’ order in place and a ward-based ceiling of care was agreed. He tested positive for COVID-19 while on a geriatric ward and subsequently developed bilateral pulmonary emboli with haemodynamic instability. The patient had a significant bleeding risk; however, the expected morbidity and mortality risk from the pulmonary emboli was high. A decision was made to give the patient low-dose thrombolysis on the geriatric ward, following which he made a full recovery. Acute thrombolysis is normally performed in emergency department, high dependency unit (HDU) or intensive care unit (ICU) settings; however, this was not possible in this case due to the burden the COVID-19 pandemic had placed on HDU/ICU services and bed capacity. Adaptation of treatment guidelines allowed for emergency life-saving treatment to be delivered to this patient.

Pulmonary embolus associated with a rare provoking factor: recreational nitrous oxide use

Pulmonary embolism (PE) is a common acute presentation which may be provoked by multiple factors. We present the unique case of a young man with no underlying health conditions who was diagnosed with bilateral PE which we believe was provoked by chronic use of nitrous oxide (NO), a potentially under-recognised risk factor for PE. NO is a substance that is commonly used recreationally, particularly among young adults in the UK. It has been shown to increase serum homocysteine levels which may create a prothrombotic state.Our patient had raised serum homocysteine levels on admission. He was anticoagulated and discharged with advice to stop nitrous oxide use. We recommend asking patients about recreational drug use when screening for provoking factors for PE so as to offer appropriate treatment and counselling.

Chest imaging in pregnant patients with COVID-19: Recommendations, justification, and optimization

Evaluation of COVID-19 related complication is challenging in pregnancy, due to concerns about ionizing radiation risk to mother and the fetus. Although there are instances when diagnostic imaging is clinically warranted for COVID-19 evaluation despite the minimal risks of radiation exposure, often there are concerns raised by the patients and sometimes by the attending physicians. This article reviews the current recommendations on indications of chest imaging in pregnant patients with COVID-19, the dose optimization strategies, and the risks related to imaging exposure during pregnancy. In clinical practice, these imaging strategies are key in addressing the complex obstetrical complications associated with COVID-19 pneumonia.

How do we identify acute medical admissions that are suitable for same day emergency care?

Medical emergencies causing unplanned hospital admission place considerable demands on acute healthcare services. Some patients can be assessed and treated through ambulatory pathways without inpatient admission, via same day emergency care (SDEC), potentially benefiting patients and reducing demands on inpatient services. There is currently considerable variation within acute medicine in aspects of SDEC delivery ranging from overall service design to patient selection methods. Scoring systems identifying patients likely to be successfully managed through SDEC services have been suggested, but evidence of utility in diverse populations is lacking. Specific scoring systems exist for some common medical problems, including cardiac chest pain and pulmonary embolism, but further research is needed to demonstrate how these are most effectively incorporated into SDEC services. This review defines SDEC and describes the variation in services nationally. It reviews the evidence for their clinical impact, tools to screen patients for SDEC and current gaps in our knowledge regarding service deployment.

Investigating the Source of Fatal Pulmonary Thromboembolism in a Coronial Postmortem Population

ABSTRACT

The incidence of how often a deep vein thrombosis is found in the calves of the legs at coronial postmortem examination is unclear. This study retrospectively examined postmortem examination reports from Australian Coronial investigations of sudden death resulting from pulmonary thromboembolism to determine the likelihood of dissection of the deep veins of calves of the legs revealing the source of a pulmonary thromboembolism. From 450 cases taken from the National Coronial Information System (NCIS) for 2016, the postmortem reports of 327 cases were reviewed to provide demographic details of victims of sudden death from pulmonary thromboembolism. In 235 cases, it was possible to determine in 76.6% a thrombus had been found in the deep veins of the calves of the legs after dissection. In 141 cases, it was documented that both sides had been examined. From these, it was determined there was no statistically significant difference in the prevalence of thrombus in either side. However, it was shown that the presence of an abnormality of a lower limb (such as leg or hip infection, burns, surgery and nonoperated fractures, or a larger circumference) increased the likelihood that a deep vein thrombus would be found on that side.

Pulmonary embolism: Age specific temporal trends in incidence and mortality in Denmark 1999-2018

BACKGROUND

Through the last two decades the prevention, diagnosis and treatment of pulmonary embolism (PE) has evolved along with demographic changes. The influence of these current transformations is important in the assessment of the future burden of PE. We aimed to describe age specific temporal trends in incidence of first-time PE and subsequent mortality.

METHODS

We identified patients ≥18 years of age with a first-time in-hospital diagnosis of PE in Danish national registers. By dividing patients into seven age groups (18-34, 35-44, 45-54, 55-65, 65-74, 75-84, >85 years), age specific incidence and 1-year mortality rates were calculated for four different calendar periods between 1999 and 2018.

RESULTS

From 1999 to 2018 65,478 patients with a first-time PE were identified. PE incidence per 100,000 person years increased during the study period in all age-groups (18-34 years: 10 to 18, 35-44 years: 18 to 35, 45-54: 26 to 63, 55-64 years: 42 to 123, 65-74 years: 92 to 229, 75-84 years: 166 to 383 and >85 years: 155 to 417), p_trend <0.0001 for all. During the study period 1-year mortality rate decreased from 4 to 2 per 10 person years in patients aged 65-74 years and this trend was found in all age groups (p_trend = 0.0001 for all).

CONCLUSION

Despite a decreasing mortality rate, incidence rate of PE increased in Denmark across all age groups from 1999 to 2018, reflecting improved sensitivity of diagnostic methods and changes in the burden of comorbid conditions, all together warranting a continuing need for early prevention of PE.

The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds

Echocardiography is being increasingly deployed as a diagnostic and monitoring tool in the critically ill. This rise in popularity has led to its recommendation as a core competence in intensive care, with several training routes available. In the peri-arrest and cardiac arrest population, point of care focused echocardiography has the potential to transform patient care and improve outcomes. Be it via diagnosis of shock aetiology and reversibility or assessing response to treatment and prognostication. This narrative review discusses current and future applications of echocardiography in this patient group and provides a structure with which one can approach such patients.

An incidental finding of testicular seminoma in the context of acute pulmonary embolism: a case report

Background

Clinical guidelines do not recommend further investigation for occult malignancy in the scenario of unprovoked venous thromboembolism in the absence of additional clinical features suggestive of malignancy. We present the case of a young gentleman with pulmonary embolism who was diagnosed with testicular seminoma despite lack of symptoms or signs suggestive of malignancy. This is a unique case describing a scenario not well documented in existing literature where contravention of clinical guidelines had a potentially advantageous outcome for the patient.

Case presentation

A 37-year-old white male presented with seemingly unprovoked acute pulmonary embolism with right heart strain. He did not have any predisposing factors for venous thromboembolism and did not have any symptoms or signs suggestive of malignancy. Clinical guidelines do not recommend further investigation to screen for malignancy in this scenario. Despite this, our young, otherwise healthy patient proceeded to computed tomography scanning, resulting in the diagnosis of localized testicular seminoma. Testicular ultrasound described normal-sized testes (despite a discrete lesion in the right testis), suggesting this was not detectable by the patient or clinician on routine examination. The patient was anticoagulated and had an inferior vena cava filter inserted to facilitate orchidectomy followed by adjuvant radiotherapy.

Conclusions

This case highlights the importance of considering malignancy in seemingly unprovoked venous thromboembolism and the availability of guidelines to direct further investigation. Our patient’s treatment was not in line with clinical guidelines and was considered a “lucky find.”

Successful Intraosseous Thrombolysis in the Management of a Massive Pulmonary Embolism With Cardiac Arrest

We describe the successful cardiopulmonary resuscitation of a patient with massive pulmonary embolism who received thrombolysis via the intraosseous route. This case also demonstrates survival without apparent long-term sequelae despite extreme metabolic acidosis. In the context of pulmonary embolism, this has not been widely reported in the existing literature. A 22-year-old woman suffered a prolonged cardiac arrest secondary to pulmonary embolism in a hospital corridor following short hospital admission for medical termination of pregnancy. A point-of-care echocardiogram showed a grossly dilated right ventricle indicative of pulmonary embolism. Due to severe peripheral vasoconstriction, intravenous access proved difficult, and the decision was made to deliver intraosseous thrombolysis. Initial blood gas analysis showed a profound acidosis due to alternating return of spontaneous circulation and further loss of output. Because of her prolonged "low-flow" state, she was deemed unsuitable for extracorporeal membrane oxygenation. Despite the poor prognosis, the decision was made to continue with resuscitation in light of a reversible pathology. She was successfully discharged from the hospital after a short intensive care stay with no long-term complications. This case demonstrates successful thrombolysis through an intraosseous route, with a good outcome despite poor prognostic factors. Early thrombolysis and continuous cardiopulmonary resuscitation in massive pulmonary embolism are imperative to survival in cardiac arrest.

Thrombolysis and use of argatroban for the treatment of massive pulmonary embolism following anticoagulation failure in a patient with COVID-19

Purpose

Successful use of alteplase and argatroban to treat a patient with coronavirus disease 2019 (COVID-19)–associated massive pulmonary embolism with cardiac arrest is reported.

Summary

This case report describes a 42-year-old male with COVID-19 who developed a massive pulmonary embolism resulting in cardiac arrest after suspected failure of low-molecular-weight heparin therapy for a deep venous thrombosis. Administration of two 50-mg doses of intravenous alteplase resulted in return of spontaneous circulation, and low-dose argatroban was used as follow-up anticoagulation therapy without complications. This is the first case report of use of argatroban in a patient with COVID-19 with cardiac arrest–associated massive pulmonary embolism after failure of previous anticoagulation efforts.

Conclusion

Argatroban may be used as an alternate anticoagulation strategy in COVID-19 patients who fail low-molecular weight therapy. A risk versus benefit discussion should be had regarding appropriateness of therapy as well as dosing. More data is needed to understand the unique hypercoagulable condition in COVID-19 patients as well as research that further highlights the role of argatroban and bivalirudin therapy in this patient population.

To Thrombolyse or Not to Thrombolyse: Two Years Experience of Thrombolysis of Sub-Massive Pulmonary Embolism in a District General Hospital

Aims

Current British Thoracic Society (BTS) guidelines only recommend thrombolysis of pulmonary embolism (PE) in patients who are haemodynamically compromised. Newer evidence suggests a mortality benefit for the thrombolysis of sub-massive PE with right ventricular strain. We wanted to assess the outcome and safety of thrombolysis in patients with sub-massive PE in a DGH.

Methods

The notes for patients with sub-massive PE and thrombolysis from a two-year period were reviewed. Evidence of right ventricular strain and myocardial necrosis based on bedside echocardiography, computed tomography (CT) scan and troponin T were indications for thrombolysis.

Results

A total of 22 patients had thrombolysis of PE in the study period (56±14 years). Fourteen patients were classified as sub-massive PE (55±15 years). Out of eight patients who had thrombolysis of massive PE (58±14 years), three were initially classified as sub-massive PE but deteriorated within the next 48 hours and became haemodynamically unstable. In all patients, the diagnosis was confirmed with a CT pulmonary angiography (CTPA).

Mean troponin was 82 in the sub-massive PE group and 102 in the massive PE group. The clinical condition and haemodynamic of patients improved rapidly within a few hours after thrombolysis.

Post-thrombolysis echocardiography was performed, 17 patients had normal right ventricles with normal pulmonary arterial pressures.

Conclusion

Thrombolysis of sub-massive pulmonary embolism is feasible in a district general hospital and seems to be a safe procedure, particularly in younger patients. It results in rapid improvement in the clinical condition of patients with a small incidence of bleeding complications.

Return of spontaneous circulation in patients with out-of-hospital cardiac arrest caused by pulmonary embolism using early point-of-care ultrasound and timely thrombolytic agent application: Two case reports

Introduction:

Acute pulmonary embolism is a confirmed cause of up to 5% of out-of-hospital cardiac arrest and 5%–13% of unexplained cardiac arrest in patients. However, the true incidence may be much higher, as pulmonary embolism is often clinically underdiagnosed. Thrombolytic therapy is a recognized therapy for pulmonary embolism–associated cardiac arrest but is not routinely recommended during cardiopulmonary resuscitation. Therefore, clinicians should attempt to identify patients with suspected pulmonary embolism. Many point-of care ultrasound protocols suggest diagnosis of pulmonary embolism for cardiac arrest patients.

Case presentation:

We describe two male patients (60 years and 66 years, respectively) who presented to the emergency department with cardiac arrest within a period of 1 week. With administration of point-of care ultrasound during the ongoing cardiopulmonary resuscitation in both patients, fibrinolytic therapy was initiated under suspicion of cardiac arrest caused by pulmonary embolism. Both patients had return of spontaneous circulation; however, only the second patient, who received fibrinolytic therapy relatively early, was discharged with a good outcome. In this report, we discussed how to diagnose and manage patients with cardiac arrest–associated pulmonary embolism with the help of point-of care ultrasound. We also discuss the different clinical outcomes of the two patients based on the experience of the clinicians and the timing of thrombolytic agent application.

Conclusions:

If acute pulmonary embolism is suspected in patients with out-of-hospital cardiac arrest, we recommend prompt point-of care ultrasound examination. Point-of care ultrasound may help identify patients with pulmonary embolism during cardiopulmonary resuscitation, leading to immediate treatment, although the clinical outcomes may vary.

Assessment of the Need for Early Initiation of Rehabilitation Treatments in Patients with Coronavirus Disease 2019

Objective

The aim of this study was to describe the clinical characteristics of coronavirus disease (COVID-19) patients, including risk factors for deep vein thrombosis and pulmonary embolism, and to evaluate the need for rehabilitation to prevent pulmonary embolism.

Methods

A retrospective medical record review was conducted of patients admitted to the study hospital with COVID-19 between April 2 and April 23, 2020. The clinical characteristics and blood test results of patients with no history on admission of oral anticoagulant use were evaluated to assess the importance of inflammation and clotting function as risk factors for pulmonary embolism.

Results

A total of 51 patients with COVID-19 were admitted during the study period. Their median age was 54.0 years (range: 41-63 years) and 38 of 51 (74.5%) were men. The most common comorbidities in men were diabetes (9/38, 23.7%) and hypertension (13/38, 34.2%). On admission, white blood cell counts were normal in both sexes, whereas C-reactive protein and hemostatic marker levels, except for the activated partial thromboplastin time, were significantly higher in men. Moreover, C-reactive protein and hemostatic marker levels were significantly higher in patients that required invasive ventilation. Two patients were diagnosed with acute pulmonary embolism, neither of whom required invasive ventilation.

Conclusions

Hypercoagulability and hyperinflammation were observed in COVID-19 patients, especially in men with high oxygen demand. We recommend anticoagulant therapy and early rehabilitation intervention to prevent pulmonary embolism in COVID-19 patients.

International Survey of Thrombolytic Use for Treatment of Cardiac Arrest Due to Massive Pulmonary Embolism

Objectives

This survey sought to characterize the national prescribing patterns and barriers to the use of thrombolytic agents in the treatment of pulmonary embolism, with a specific focus on treatment during actual or imminent cardiac arrest.

Design

A 19-question international, cross-sectional survey on thrombolytic use in pulmonary embolism was developed, validated, and administered. A multivariable logistic regression was conducted to determine factors predictive of utilization of thrombolytics in the setting of cardiac arrest secondary to pulmonary embolism.

Setting

International survey study.

Subjects

Physicians, pharmacists, nurses, and other healthcare professionals who were members of the Society of Critical Care Medicine.

Interventions

None.

Measurements and Main Results

Thrombolytic users were compared with nonusers. Respondents (n = 272) predominately were physicians (62.1%) or pharmacists (30.5%) practicing in an academic medical center (54.8%) or community teaching setting (24.6%). Thrombolytic users (n = 177; 66.8%) were compared with nonusers (n = 88; 33.2%) Thrombolytic users were more likely to work in pulmonary/critical care (80.2% thrombolytic use vs 59.8%; p < 0.01) and emergency medicine (6.8% vs 3.5%; p < 0.01). Users were more likely to have an institutional guideline or policy in place pertaining to the use of thrombolytics in cardiac arrest (27.8% vs 13.6%; p < 0.01) or have a pulmonary embolism response team (38.6% vs 19.3%; p < 0.01). Lack of evidence supporting use and the risk of adverse outcomes were barriers to thrombolytic use. Working in a pulmonary/critical care environment (odds ratio, 2.36; 95% CI, 1.24-4.52) and comfort level (odds ratio, 2.77; 95% CI, 1.7-4.53) were predictive of thrombolytic use in the multivariable analysis.

Conclusions

Most survey respondents used thrombolytics in the setting of cardiac arrest secondary to known or suspected pulmonary embolism. This survey study adds important data to the literature surrounding thrombolytics for pulmonary embolism as it describes thrombolytic user characteristic, barriers to use, and common prescribing practices internationally.

Massive pulmonary embolism in pregnancy: intra-arrest thrombolysis and resuscitative hysterotomy

Massive pulmonary embolism (PE) is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy. The case presented is a primigravida in her mid-30s at 28 weeks gestation. The patient presented to the emergency department after out-of-hospital cardiac arrest. Return of spontaneous circulation (ROSC) was achieved but not sustained. Episodic cardiopulmonary resuscitation with epinephrine boluses was required. Resuscitative hysterotomy was performed intra-arrest. Echocardiography revealed a dilated right heart consistent with massive PE and thrombolysis was administered. ROSC was obtained thereafter and output was sustained. Subsequent CT brain revealed irreversible hypoxic injury. Treatment was withdrawn with the support of family. Postmortem examination confirmed massive PE. Thrombolysis can restore and improve cardiovascular status in cardiac arrest caused by massive PE. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.

CUSHING'S SYNDROME, A RISK FACTOR FOR VENOUS THROMBOEMBOLISM IS A CANDIDATE FOR GUIDELINES

OBJECTIVES

The present paper aims to review important contemporary information about VTE risk in endogenous and exogenous CS, as a substantial discrepancy exists between the results of a recent meta-analysis confirming the increased risk for VTE and the absence of CS in VTE guidelines.

METHODS

An extensive search of relevant databases (e.g. PubMed, Google Scholar, and Scopus) was performed in order to establish the interconnectedness of the following terms: Cushing's syndrome, venous thromboembolism, deep vein thrombosis, pulmonary embolism.

RESULTS

The analysis demonstrated that patients with CS have about ten times the risk for VTE, particularly during the first year following the diagnosis of CS. Oral glucocorticoid users (with iatrogenic CS) have a 3-fold increase in risk of VTE in comparison with non-users. The most recent 2019 meta-analysis encompassed 7142 patients with endogenous CS (including Cushing's disease) undergoing transsphenoidal surgery or adrenalectomy, and their risk of unprovoked VTE was almost 18 times higher in comparison with a healthy population.

CONCLUSION

Over the past 50 years considerable evidence of increased VTE risk in CS has been accumulated. It pertains to both endogenous and exogenous type of CS and has been confirmed in the vast majority, if not all the available studies, including meta-analyses. Nevertheless, official CS guidelines make no mention of CS as a VTE risk factor, even though it is important that not only physicians who treat CS, but also physicians who manage patients with suspected VTE be aware of increased VTE risk.

Outpatient management of pulmonary emboli: when to ambulate

Pulmonary embolism is a potentially fatal consequence of venous thromboembolism and constitutes a significant proportion of the acute medical take. Standard management has previously required admission of all patients presenting with acute pulmonary embolism for initiation of anticoagulation and initial investigations. However, clinical trial data have demonstrated the feasibility and safety of managing a subset of patients with low-risk pulmonary embolism in the outpatient setting and this has since been reflected in national guidelines. This article provides a practical overview for general physicians with regards to identifying patients with low-risk pulmonary embolism, and when and how to manage these patients on an outpatient basis.

The diagnosis and management of pulmonary embolism

Pulmonary embolism (PE) is a condition characterised by an obstruction of the pulmonary arterial system by one or more emboli. Advanced clinical practitioners are often faced with ruling out a diagnosis of PE in patients with non-specific symptoms such as dyspnoea and pleuritic chest pain, which can be fairly mild and therefore a diagnosis of PE easily missed. PEs can be a challenge to diagnose, especially in elderly people, since it can be difficult to differentiate their symptoms from other less serious illnesses. Widely used scoring tools are helpful to calculate a patient's probability of having a PE. The Wells score is the most widely used pre-test clinical probability indicator of PE used in the UK, which scores the patient's probability of having a PE based on their risk factors. The D-dimer test is a relatively simple investigation to rule out venous thromboembolism (VTE) but can be raised for various reasons other than PE. Computed tomography pulmonary angiography (CTPA) is regarded as the gold standard imaging modality for investigation of acute PE but ventilation-perfusion (VQ) scans can be used as an alternative imaging technique for diagnosing PE in those where CTPA is contraindicated. Thrombolysis is underused in clinical practice due to the fear of adverse bleeding events. Patients without a massive or sub-massive PE are treated with anticoagulant therapy, usually commencing with subcutaneous low-molecular-weight heparin and switching over to a direct oral anticoagulant (DOAC). There has been a shift away from treatment with warfarin for the prevention and treatment of VTE over the past decade.

Ambulatory management of pulmonary embolism

The diagnosis of pulmonary embolism can be very difficult and elusive. It depends greatly on the use of diagnostic tests, which are in turn interpreted according to a pre-test clinical probability. These include non-specific tests such as the chest X-ray and electrocardiograph, which help exclude other conditions such as pneumonia or myocardial infarction. On the other hand, more specific tests such as computed tomography or ventilation/perfusion scanning are used to confirm or exclude the diagnosis of pulmonary embolism. The condition is potentially fatal, and in the past patients with suspected pulmonary embolism constituted a significant number of hospital admissions. Despite this, the majority were found not to have pulmonary embolism. More recently, studies have suggested that most patients with suspected pulmonary embolism who are haemodynamically stable can be safely managed on an ambulatory pathway. Therefore, there is a paradigm shift towards investigating and treating pulmonary embolism in the outpatient setting. This article discusses the ambulatory pathway of the diagnosis and treatment of pulmonary embolism.

Characterization of alteplase therapy for presumed or confirmed pulmonary embolism during cardiac arrest

PURPOSE

The dosing and administration of alteplase in cardiac arrest due to suspected or confirmed pulmonary embolism (PE) are characterized.

METHODS

This multicenter, retrospective, cohort study evaluated adult patients who received alteplase during PE-induced cardiac arrest at 16 medical centers. Outcomes analyzed included alteplase dosing characteristics, cardiopulmonary resuscitation survival, time to return of spontaneous circulation (ROSC), documented occurrence of major or minor bleeding, intensive care unit and hospital length of stay, and survival to discharge.

RESULTS

A total of 35 patients were included in the analysis. Forty-six percent of patients received alteplase by a bolus-only dosing strategy. The most common bolus-only alteplase dose was 50 mg. Patients in the bolus-only group had a significantly shorter mean time from cardiac arrest onset to alteplase administration (15.1 minutes) compared with both the infusion-only group (46.4 minutes) and the bolus-with-infusion group (48.0 minutes) (p = 0.006). The mean cumulative alteplase dose was significantly higher in patients who had ROSC than those who did not (90.6 and 69.4 mg, respectively; p = 0.03). Although there was a significant difference in the cardiac arrest survival between groups, there was no difference between dosing strategies and the attainment of ROSC, and survival to hospital discharge.

CONCLUSION

Among patients receiving alteplase for presumed or confirmed PE during cardiac arrest, the most common treatment was administration of a single 50-mg bolus of the thrombolytic agent. This treatment was received by all survivors of cardiac arrest.

Clinical Probability Tools for Deep Venous Thrombosis, Pulmonary Embolism, and Bleeding

Overdiagnosis of venous thromboembolism is associated with increasing numbers of patient complications and health care burden. Multiple clinical tools exist to estimate the probability of pulmonary embolism and deep venous thrombosis. When used with d-dimer testing, these can further stratify venous thromboembolism risk to help inform the use of additional diagnostic testing. Although there are similar tools to estimate bleeding risk, these are not as well-validated and lack reliability.

Management of Low-Risk Pulmonary Embolism

Pulmonary embolism remains a leading cause of morbidity and mortality in the United States. However, with improved recognition and diagnosis, the risk of death diminishes. The diagnosis depends on the clinician's suspicion. Pulmonary emboli are categorized into low, intermediate, or high risk based on the scoring scales and patients' hemodynamic stability versus instability. Imaging plus biomarkers help stratify patients according to risk. With the advent of the computed tomography multidetector scanners, the improved imaging has increased the detection of subsegmental and incidental pulmonary emboli. Treatment of low-risk as well as subsegmental and incidental pulmonary embolism is evolving.

Kidney and inferior vena cava abnormalities with leg thromboses (KILT) syndrome: A case report and literature review

Venous thromboembolism (VTE) is now increasingly recognized within paediatrics. A Canadian VTE registry has estimated the incidence as 0.7 to 1.0 per 100,000 population, with a peak in infancy and adolescence. Congenital inferior vena cava agenesis (IVCA) is an important risk factor that may be unfamiliar to paediatricians. Several case reports have since described an association between IVCA, VTE, and renal hypoplasia, which has been referred to as KILT syndrome (Kidney and IVC abnormalities with Leg Thromboses). We describe the first reported paediatric case of KILT syndrome in Canada. In any young patient presenting with a spontaneous DVT, particularly, if it is bilateral in nature with no co-existing risk factors for thrombus formation, we recommend investigating for the possibility of an underlying congenital vena cava anomaly. The use of prolonged anticoagulant therapy is supported by the inherent life-long risk of recurrent thrombosis associated with IVC anomalies.

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

BACKGROUND

Pulmonary embolism is one of the leading causes of maternal death in the Western world. Because of the low specificity and sensitivity of the d-dimer test, all pregnant women with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary angiography or ventilation-perfusion scanning, both of which involve radiation exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could be used to safely avoid diagnostic imaging in pregnant women with suspected pulmonary embolism is unknown.

METHODS

In a prospective study involving pregnant women with suspected pulmonary embolism, we assessed three criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the d-dimer level. Pulmonary embolism was ruled out if none of the three criteria were met and the d-dimer level was less than 1000 ng per milliliter or if one or more of the three criteria were met and the d-dimer level was less than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep-vein thrombosis; if the results were positive (i.e., a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism.

RESULTS

A total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval [CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to 44). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester.

CONCLUSIONS

Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients. (Funded by Leiden University Medical Center and 17 other participating hospitals; Artemis Netherlands Trial Register number, NL5726.).

Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study

BACKGROUND

Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests.

OBJECTIVE

To prospectively validate a diagnostic strategy in pregnant women with suspected PE.

DESIGN

Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454).

SETTING

11 centers in France and Switzerland between August 2008 and July 2016.

PATIENTS

Pregnant women with clinically suspected PE in emergency departments.

INTERVENTION

Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months.

MEASUREMENTS

The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up.

RESULTS

441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up.

LIMITATION

There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE.

CONCLUSION

A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women.

PRIMARY FUNDING SOURCE

Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.

Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens

Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.

Value of D-dimer levels for the diagnosis of pulmonary embolism: An analysis of 32 cases with computed tomography pulmonary angiography

D-dimer levels correlate with the extent of pulmonary embolism (PE) on computed tomography pulmonary angiography (CTPA), but the use of D-dimer alone for screening and diagnosing PE remains controversial. This study compared the utility of plasma D-dimer levels for diagnosing PE with that of CTPA (gold standard). This was a retrospective analysis of 32 consecutive patients with suspected PE at the Affiliated Hospital of Yan'an University between OctoberC 2010 and March 2011. Blood was sampled before thrombolytic therapy was administered. D-dimer levels were measured using an automatic system. CTPA was used to diagnose PE and was performed within 48 h of blood sampling using a Siemens Somatom Sensation 64 computed tomography (CT) scanner. ROC curve analysis was performed to evaluate the diagnostic utility of D-dimer levels, with CTPA as the gold standard. Among the 32 patients, CTPA identified 26 patients with PE and 6 patients without obvious abnormality. Using a threshold value of 1.3 µg/ml for D-dimer level, the diagnosis of PE was achieved with a sensitivity of 96.2%, specificity of 50.0%, positive predictive value of 89.3%, negative predictive value of 75.0% and accuracy of 87.5%. D-dimer levels were significantly higher in patients positive for PE on CTPA than in those negative for PE on CTPA (9.85±7.14 vs. 2.82±2.65 µg/ml, P=0.001). Based on ROC curve analysis, the optimal threshold value for D-dimer level in the diagnosis of PE was 1.9 µg/ml. To conclude, D-dimer could be a simple, fast and inexpensive screening method for excluding a diagnosis of PE.

A Clinically Meaningful Interpretation of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and III Data

RATIONALE AND OBJECTIVES

This study aimed to calculate the multiple-level likelihood ratios (LRs) and posttest probabilities for a positive, indeterminate, or negative test result for multidetector computed tomography pulmonary angiography (MDCTPA) ± computed tomography venography (CTV) and magnetic resonance pulmonary angiography (MRPA) ± magnetic resonance venography (MRV) for each clinical probability level (two-, three-, and four-level) for the nine most commonly used clinical prediction rules (CPRs) (Wells, Geneva, Miniati, and Charlotte). The study design is a review of observational studies with critical review of multiple cohort studies. The settings are acute care, emergency room care, and ambulatory care (inpatients and outpatients).

MATERIALS AND METHODS

Data were used to estimate pulmonary embolism (PE) pretest probability for each of the most commonly used CPRs at each probability level. Multiple-level LRs (positive, indeterminate, negative test) were generated and used to calculate posttest probabilities for MDCTPA, MDCTPA + CTV, MRPA, and MRPA + MRV from sensitivity and specificity results from Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and PIOPED III for each clinical probability level for each CPR. Nomograms were also created.

RESULTS

The LRs for a positive test result were higher for MRPA compared to MDCTPA without venography (76 vs 20) and with venography (42 vs 18). LRs for a negative test result were lower for MDCTPA compared to MRPA without venography (0.18 vs 0.22) and with venography (0.12 vs 0.15). In the three-level Wells score, the pretest clinical probability of PE for a low, moderate, and high clinical probability score is 5.7, 23, and 49. The posttest probability for an initially low clinical probability PE for a positive, indeterminate, and negative test result, respectively, for MDCTPA is 54, 5 and 1; for MDCTPA + CTV is 52, 2, and 0.7; for MRPA is 82, 6, and 1; and for MRPA + MRV is 72, 3, and 1; for an initially moderate clinical probability PE for MDCTPA is 86, 22, and 5; for MDCTPA + CTV is 85, 10, and 4; for MRPA is 96, 25, and 6; and for MRPA + MRV is 93, 14, and 4; and for an initially high clinical probability of PE for MDCTPA is 95, 47, and 15; for MDCTPA + CTV is 95, 27, and 10; for MRPA is 99, 52, and 17; and for MRPA + MRV is 98, 34, and 13.

CONCLUSIONS

For a positive test result, LRs were considerably higher for MRPA compared to MDCTPA. However, both a positive MRPA and MDCTPA have LRs >10 and therefore can confirm the presence of PE. Performing venography reduced the LR for a positive and negative test for both MDCTPA and MRPA. The nomograms give posttest probabilities for a positive, indeterminate, or negative test result for MDCTPA and MRPA (with and without venography) for each clinical probability level for each of the CPR.

CT Pulmonary Angiography in Young Women

The purpose was to determine whether young women in the emergency department who received computed tomographic (CT) pulmonary angiograms were evaluated to receive lower dose imaging or no imaging, recognizing that the risks of radiation are particularly high in young women. This was a retrospective cohort investigation of women aged 18 to 29 years seen for suspected acute pulmonary embolism in emergency departments of 5 regional hospitals from May 1, 2015 to April 30, 2016. Computed tomographic (CT) pulmonary angiograms were obtained in 379 young women. Pulmonary embolism was diagnosed by CT angiography in 2.1%. A Wells probability score could be calculated in 11.9%. D-dimer was obtained in 46.2% and a chest radiograph was obtained in 41.7%. Among patients with a normal chest radiograph, 3.9% had a lung scan. Venous ultrasound of the lower extremities was obtained in 1.8%. Each had an elevated D-dimer. Among the young women who received CT angiograms, 53 were pregnant. In 17.0% of pregnant women, a Wells clinical probability score could be calculated from the medical record. D-dimer in pregnant women was obtained in 30.2%, chest radiograph in 22.6%, lung scan in 11.3%, and venous ultrasound of the lower extremities in none. In conclusion, young women and pregnant women often received CT pulmonary angiograms for suspected acute pulmonary embolism without an objective clinical assessment, measurement of D-dimer, lung scintiscan, or venous ultrasound, which may have eliminated the need for CT pulmonary angiography in many instances.

Double Bolus Alteplase Therapy during Cardiopulmonary Resuscitation for Cardiac Arrest due to Massive Pulmonary Embolism Guided by Focused Bedside Echocardiography

Massive pulmonary embolism (PE) frequently leads to cardiac arrest (CA) which carries an extremely high mortality rate. Although available, randomized trials have not shown survival benefits from thrombolytic use. Thrombolytics however have been used successfully during resuscitation in clinical practice in multiple case reports and in retrospective studies. Recent resuscitation guidelines recommend using alteplase for PE related CA; however they do not offer a standardized treatment regimen. The most consistently applied approach is an intravenous bolus of 50 mg tissue plasminogen activator (t-PA) early during cardiopulmonary resuscitation (CPR). There is no consensus on the subsequent dosing. We present a case in which two 50 mg boluses of t-PA were administered 20 minutes apart during CPR due to persistent hemodynamic compromise guided by bedside echocardiogram. The patient had an excellent outcome with normalization of cardiac function and no neurologic sequela. This case demonstrates the benefit of utilizing bedside echocardiography to guide administration of a second bolus of alteplase when there is persistent hemodynamic compromise despite achieving return of spontaneous circulation after the initial bolus, and there is evidence of persistent right ventricle dysfunction. Future trials are warranted to help establish guidelines for thrombolytic use in cardiac arrest to maximize safety and efficacy.

The diagnostic utility of D-dimer and other clinical variables in pregnant and post-partum patients with suspected acute pulmonary embolism

BACKGROUND

Pulmonary embolism (PE) during pregnancy remains one of the leading causes of maternal morbidity and mortality in the developed world. However, there is a paucity of high-quality evidence resulting in a lack of consensus in managing this group of patients. The aims of the study were to address the diagnostic utility of D-dimer for suspected PE in pregnant and post-partum patients and to identify any clinical presentation variables that are predictors of PE in this group of patients.

METHODS

A retrospective case note review of 152 pregnant and post-partum patients who underwent diagnostic imaging (ventilation/perfusion (V/Q) or computed tomographic pulmonary angiography (CTPA)) for suspected PE at a tertiary teaching hospital from 2007 to 2011 was conducted. The reference range for D-dimer was less than 0.5 mg/L as being normal. The following variables were also assessed in terms of their predictive capability for PE diagnosis in pregnancy: heart rate (HR), mean arterial pressure (MAP), shock index (SI) and A-a gradient.

RESULTS

The application of D-dimer testing for suspected PE in this study population had a sensitivity of 100% (95% CI, 73-100%), specificity of 42% (95% CI, 31-53%) and a likelihood negative ratio of 0. None of the clinical variables were significant predictors of PE according to regression analyses.

CONCLUSIONS

There is supportive evidence that a negative D-dimer result is useful as a means of ruling out PE in pregnant and post-partum patients. However, we need a larger prospective observational study to collaborate the findings.