Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department

Kline, Jeffrey A.; Webb, William B.; Jones, Alan E.; Hernandez‐Nino, Jackeline

doi:10.1016/j.annemergmed.2004.03.018

Cited by 85 publications

(88 citation statements)

References 37 publications

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“…In contrast, the alveolar dead space, specifically, will present an increase when occurring during PE. Either in experimental studies [21][22][23][24][25], or in clinical studies [2,4,8,[10][11][12], this is a real finding. In the present study, the P(a-et)CO 2 and AVDSf variables indicated the significant increase in this space, from 4.8±2.8 (T 0 ) to 37.2±5.8 mmHg (T 1 ) and from 0.09±0.05 (T 0 ) to 0.59±0.06 (T 1 ), respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Since most patients with diagnostic suspicion of PE use hospital emergency services in spontaneous breathing and environmental air [10], bibliographic data, especially experimental ones, which could provide values of hemodynamic, gasometric and capnographic variables under these conditions (spontaneous breathing and environmental air), contributed greatly to a more specific and detailed comprehension of cardiopulmonary and gasometric alterations in the acute phase of the disease, leading to possible interventions.…”

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confidence: 99%

“…Given the real difficulty in performing immediate comprobatory diagnostic exams, capnography may be an auxiliary exam of great value [4,8,[10][11][12]. When associated with arterial gasometry, more specifically with partial pressure of CO 2 in arterial blood (PaCO 2 ), among other variables, it allows calculating the alveolar dead space fraction [4,8,[10][11][12].…”

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confidence: 99%

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Embolia pulmonar quase fatal, um modelo experimental

Pereira¹,

Moreira²,

Paschoal³

et al. 2011

Rev Bras Cir Cardiovasc

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Embolia pulmonar quase fatal, um modelo experimental: variáveis hemodinâmicas, gasométricas e capnográficasNear-fatal pulmonary embolism in an experimental model: hemodynamic, gasometric and capnographic variables Abstract Introduction: Experimental studies on pulmonary embolism (PE) are usually performed under mechanical ventilation. Most patients with suspicion of PE enter the Emergency Services in spontaneous breathing and environmental air. Thus, under these conditions, measurements of hemodynamic, gasometric and capnographic variables contribute largely to a more specific comprehension of cardiopulmonary and gasometric alterations in the acute phase of the disease. Studies which evaluated animals under conditions are lacking.Objective: This study aimed to submit animals under spontaneous ventilation and without supplemental oxygen to PE.Methods: PE was induced in six pigs using autologous blood clots, and cardiorespiratory and gasometric records were performed before and after PE. The values of "near fatal" mean pulmonary arterial pressure (MPAP) were previously determined.Results Conclusion: In this model, the near fatal MPAP was from 2 to 2.5 times the basal MPAP; and the capnographic variables, associated with arterial and venous gasometry, showed effective in discriminating an acute obstructive profile.Descriptors: Pulmonary embolism. Hypertension, pulmonary. Capnography. Models, animal. Swine. ResumoIntrodução: Estudos experimentais de embolia pulmonar (EP) são habitualmente realizados sob ventilação mecânica. A maioria dos pacientes com suspeita de EP adentra os Serviços de Emergência em respiração espontânea e em ar ambiente. Assim, medidas das variáveis hemodinâmicas, gasométricas e capnográficas, nessas condições, em muito Universitária "Zeferino Vaz"

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Embolia pulmonar quase fatal, um modelo experimental

Pereira¹,

Moreira²,

Paschoal³

et al. 2011

Rev Bras Cir Cardiovasc

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“…Currently, approximately 10% of ED patients receive either a computed tomography (CT) scan or magnetic resonance imaging as a part of their ED care, and more than 1% receive pulmonary vascular imaging by CT to evaluate for PE. [2][3][4][5] This rate has increased more than fivefold in the past 5 years, thus increasing the overall exposure of ED patients to ionizing radiation and contrast material. [6][7][8][9] Emergency physicians need well-studied, noninvasive strategies to effectively screen ED patients suspected of PE.…”

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confidence: 99%

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Mitchell

Nordenholz

Kline

2008

Academic Emergency Medicine

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Objectives: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone.Methods: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. Results:The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff ‡ 500 ng ⁄ mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115 ⁄ 304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg ⁄ dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of )13% = )5% to )20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. Conclusions:The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively. ACADEMIC EMERGENCY MEDICINE 2008; 15:800-805 ª 2008 by the Society for Academic Emergency MedicineKeywords: biological markers, pulmonary embolism E mergency physicians' awareness of pulmonary embolism (PE) as an important and potentially life-threatening illness is increasing. Currently, emergency physicians employ a diagnostic strategy that involves an assessment of pretest probability based on clinical evaluation followed by D-dimer testing in low-and moderate-risk patients. Patients with a positive D-dimer, or those at high risk, generally defined as a pretest probability for venous thromboembolism (VTE) of about 40% or greater, go on to pulmonary vascular imaging.1 While the D-dimer has proven to be a sensitive marker for PE, a low specificity leads to frequent negative pulmonary vascular imaging.Pulmonary vascular imaging is a significant source of the overall increase in imaging studies performed in emergency departments (EDs). Currently, approximately 10% of ED patients receive either a computed tomography (CT) scan or magnetic resonance imaging as a part of their ED care, and more than 1% receive

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“…Non-invasive diagnostic modalities have been accepted and different combination of clinical assessment, lower extremity color ultrasonography, D-dimer measurement, V/Q lung scintigraphy and, recently, CT have been considered to eliminate the need for pulmonary angiography. These modalities are used in suspected PE patients in emergency setting or during hospitalization (16,17). Diagnostic evaluation of suspected PE patients has improved by development of standardized clinical decision rules (CDRs), which show the clinical chance of PE.…”

Section: Discussionmentioning

confidence: 99%

Correlation of the Wells and Simplified Revised Geneva Scores with CT Pulmonary Artery Obstruction Index in Pulmonary Embolism

2017

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Background: The pulmonary artery obstruction index (PAOI), which is evaluated by the CT pulmonary angiography, offers an objective method to measure the severity of pulmonary arteries obstruction. Objectives: We decided to investigate the correlation between the PAOI determined by CT pulmonary angiography, as an index to determine the severity of pulmonary embolism (PE), with two clinical models used for predicting the probability of acute PE, namely the Wells criteria and the simplified revised Geneva score. Patients and Methods: Sixty-four consecutive patients with definite diagnosis of acute PE based on CT pulmonary angiography were enrolled. The Wells score as well as simplified revised Geneva score were calculated retrospectively using the medical records. Then, the PAOI was determined by CT pulmonary angiography. By applying the Pearson's correlation coefficient, the relationships were investigated. Results: The Wells score had a weak correlation with the PAOI (r = 0.29; P = 0.01). The simplified revised Geneva score did not have significant correlation with the PAOI (r = 0.1; P = 0.2). Furthermore, patients with active cancer had significantly higher CT indexes than the other patients with PE (P = 0.046). Conclusion: Although the Wells and simplified revised Geneva scores are used widely for assessing clinical probability of PE, these scores may not necessarily correlate with the severity of PE. The Wells score had a weak correlation and may somehow predict the severity of PE. Malignancy is a significant risk factor found to be correlated with more severe PE.

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Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department

Cited by 85 publications

References 37 publications

Embolia pulmonar quase fatal, um modelo experimental

Embolia pulmonar quase fatal, um modelo experimental

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Correlation of the Wells and Simplified Revised Geneva Scores with CT Pulmonary Artery Obstruction Index in Pulmonary Embolism

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