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practice updates

Outpatient PE treatment

Editor's note: This post was listed in the LITFL Review 153's "Best of #FOAMed" category. Venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) has an incidence of roughly 1 in 1,000 with an incidence of PE with or without DVT of 2.3 per 10,000. One major factor to consider is that VTE is much more common in the elderly and has a mortality highly associated with co-morbidities such as cancer and underlying cardiovascular disease. In the distant past any diagnosis of DVT and/or PE would result in admission for heparin bridging to oral anticoagulation therapy. This was largely due to a fear that outpatient management would lead to an increase in fatal embolic or major bleeding events. However, there is a great amount of literature that has established the safety of outpatient management of “low-risk” DVT; outpatient treatment has become standard of care for these patients. “Low-risk” patients were those with no prior VTE, no PE, no prior heparin use, and no confounding co-morbidities (cancer, infection, stroke, etc). So what about PE? If outpatient management is standard of care for a select group of DVT patients, then can we treat PE as an outpatient? [...]

happenings

PE and Evaluation of Risk: Pik Mukherji (AllNYCEM6)

"More a story of over-testing than risk"
The 6th All NYC EM Conference was held on March 12, 2014 at the NY Academy of Medicine. There were some fantastic talks, with highlights tweeted throughout on #AllNYCEM6. A contingent of the emDocs team was also there, taking lots of notes so we can now present to you a more detailed summary of Dr. Pik Mukherji's (@ercowboy) excellent lecture on pulmonary embolism and the current state of testing and treatment in the ED.

practice updates

PERC Rule: Application and Limitations

"Pleuritic chest pain [...] is not in a validated clinical decision rule despite having a higher OR for PE than hemoptysis and recent immobilization"
The PERC rule can be a wonderful thing, but requires judicious use. Jason West, MD reviews the literature, discussing applicability and limitations of the PERC rule, so you'll know when to feel confident foregoing the D-dimer and when to be more cautious.

From @EMSwami

Furosemide in the Treatment of Acute Pulmonary Edema

"The continued central role [loop diuretics] play highlights a lack of understanding of the underlying pathophysiology of the disease"

In this excellent article, Anand Swaminathan, MD, MPH dissects the evidence to challenge common perceptions regarding the utility of furosemide in patients with APE.