JournalFeed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Scan ‘Em All – Anticoagulated Minor Head Trauma

Spoon Feed
Incidence of intracerebral hemorrhage (ICH) on CT following minor head trauma in anticoagulated patients was 9%, which means we have to CT all these people.

Why does this matter?
Guidelines recommend CT for anticoagulated patients who have minor head trauma, including NICE and the CDC.  Do we really need to do that?  Yup…we do.

Scan ’em all
They started with over 10,000 studies and whittled it down to just 5 that met criteria.  Almost all had low risk of bias.  In this meta-analysis of these 5 prospective studies with 4080 anticoagulated patients with head injury and GCS 15, the incidence of initial or delayed ICH on CT was 9%.  When the study with greater risk of bias was removed from the analysis, incidence of ICH was 11%.  Of these, 98% were taking warfarin.  The newer direct oral anticoagulants and LMWH were not well represented.  The implication of this is that patients who are anticoagulated need a head CT even if they look well and have normal GCS.  Incidence of intracranial findings is too high to safely avoid it.

Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies.  Br J Haematol. 2018 Jul 20. doi: 10.1111/bjh.15509. [Epub ahead of print]
Open in Read by QxMD

Another Spoonful

emDocs on disposition of the anticoagulated patient with ICH

Another Spoonful

EM Lit of Note came to a similar conclusion.

Another Spoonful

ALiEM posted a review of the literature a couple years back.

#2: Syncope – Costly, Low-Yield Tests to Avoid

Spoon Feed
The higher cost, lower yield tests to consider avoiding for patients ≥60 with syncope were: EEG, head CT, MRA, cardiac stress test, and EP study.

Why does this matter?
Syncope is a target diagnosis for Medicare to retrospectively audit and decide an admission was “unnecessary.”  Given that in this cohort alone the serious 30-day adverse event rate was 25.1%, including such things as MI, stroke, major hemorrhage, SAH, etc, it seems a bit “armchair quarterback-ish” for Medicare to do this.  Regardless, there are some low-yield diagnostic tests that may be targets for cost reduction.

DFO (done fell out) workup
This was a prospective multicenter study of 3686 patients ≥60 with syncope or presyncope.  The goal was to observe the variability, frequency, yield, and cost of the workup.  All patients had a standardized H&P + ECG.  Ironically, the second lowest yield test was ECG, with only 1.9% of tests abnormal, just behind troponin at 1.3%.  Coronary angiography was infrequently done but had the highest overall proportion of abnormal results at 42%.  The most commonly ordered test was troponin in 88%.  The most widely variable from hospital to hospital was carotid ultrasound.  The most expensive when considering cost per abnormal test was electrophysiology (EP) study at $39,703 per abnormal test.  The highest total expense was echocardiogram at $672,648.  Of the top 5 tests ordered, echo had the highest proportion of abnormal results at 22%.  The biggest outliers in cost per abnormal result were cardiac stress tests, coronary angiogram, EEG, MRA, and EP study.  The higher cost, lower yield tests to consider avoiding without a compelling indication were: EEG, head CT, MRA, cardiac stress test, and EP study. Here is a table sorted by percent with an abnormal finding from lowest to highest.

Screen Shot 2018-08-26 at 3.47.58 PM.png
Variation in diagnostic testing for older patients with syncope in the emergency department.  Am J Emerg Med. 2018 Jul 23. pii: S0735-6757(18)30623-5. doi: 10.1016/j.ajem.2018.07.043. [Epub ahead of print]
Open in Read by QxMD
Another Spoonful

#3: PE Workup in 5 Steps

Download the latest JournalFeed Infographic: PE Workup in 5 Steps

Click here to download a PDF version.

Click here for the JournalFeed Pop Quiz of the week!



This figure is a composite of the great ideas of others, with some adaptation on my part.  The following is a list of the resources that went into making this figure.  I’m standing on their shoulders.

  1. Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haem. 2008;6:772–80.
  2. Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV, et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005;25: 843–8.
  3. Douma RA, Mos ICM, Erkins PMG, Nizet TAC, Durian MF, Hovens MM, et al. Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism – A Prospective Cohort Study. Ann Intern Med. 2011;154:709-18.
  4. Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, et al. Comparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism. Ann Emerg Med. 2013;62:117-24.
  5. Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371:1343–52.
  6. Huisman MV for the Christopher Study Investigators. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA. 2006;295:172-9.
  7. Donze J, Le Gal G, Fine MJ, Roy PM, Sanchez O, Verschuren F, et al. Prospective validation of the pulmonary embolism severity index – a clinical prognostic model for pulmonary embolism. Thromb Haemost. 2008; 100:943–8.
  8. Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost. 2010; 8:1509–14.
  9. Jimenez D, Aujesky D, Moores L, Gomez V, Lobo JL, Uresandi F, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010; 170:1383–89.
  10. Righini M, Roy PM, Meyer G, Verschuren F, Aujesky D, Le Gal G. The simplified pulmonary embolism severity index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost. 2011; 9:2115–17.
  11. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism – a meta-analysis. Circulation. 2007; 116:427–33.
  12. Jimenez D, Uresandi F, Otero R, Lobo JL, Monreal M, Marti D, Zamora J, et al. Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism – systematic review and metaanalysis. Chest. 2009;136:974–82.
  13. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Peripheral Vascular Disease, and Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788 –1830.
  14. Konstantinides S, Goldhaber SZ. Pulmonary embolism: risk assessment and management. Eur Heart J. 2012 Dec;33(24):3014-22. doi: 10.1093/eurheartj/ehs258. Epub 2012 Sep 7.
  15. Dresden S, Mitchell P, Rahimi L, Leo M, Rubin-Smith J, Bibi S, et al. Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism. Ann Emerg Med. 2014;63:16-24.
  16. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000;101:2817–22.
  17. Otero R, Trujillo-Santos J, Cayuela A, Rodriguez C, Barron M, Martin JJ, et al for the Registro Informatizado de la Enfermedad Tromboembólica (RIETE) Investigators. Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index? Eur Respir J. 2007;30(6):1111-6.
  18. Thabut G, Thabut D, Myers RP, Bernard-Chabert B, Marrash-Chahla R, Mal H, et al. Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol. 2002;40:1660–67.
  19. Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378(9785):41-8.
  20. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral Apixaban for the Treatment of Acute Venous Thromboembolism. N Engl J Med. 2013;369:799-808.
  21. Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al for the RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361:2342–52.
  22. Büller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al for the EINSTEIN–PE Investigators. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287-97.
  23. Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdepour M. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013;111(2):273-7.
  24. Huisman et al. How I diagnose acute pulmonary embolism. Blood. 2013;121(22):4443-4448.
  25. Penaloza et al. Risk stratification and treatment strategy of PE. Curr Opin Crit Care 2012, 18:318–325.
  26. Konstantinides SV, Vicaut E, Danays T, Becattini C, Bertoletti L, Beyer-Westendorf J, et al. Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol. 2017 Mar 28;69(12):1536-1544. doi: 10.1016/j.jacc.2016.12.039.
  27. Freund Y, Cachanado M, Aubry A, Orsini C, Raynal PA, Féral-Pierssens AL, et al, PROPER Investigator Group. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA. 2018 Feb 13;319(6):559-566. doi: 10.1001/jama.2017.21904.
  28. Belzile D, Jacquet S, Bertoletti L, Lacasse Y, Lambert C, Lega JC, Provencher S. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysis of the management outcome studies. J Thromb Haemost. 2018 Jun;16(6):1107-1120. doi: 10.1111/jth.14021. Epub 2018 May 17.
  29. Righini M, Robert-Ebadi H, Le Gal G. Diagnosis of acute pulmonary embolism. J Thromb Haemost. 2017 Jul;15(7):1251-1261. doi: 10.1111/jth.13694.
  30. Wolf SJ, Hahn SA, Nentwich LM, Raja AS, Silvers SM, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med. 2018 May;71(5):e59-e109. doi: 10.1016/j.annemergmed.2018.03.006.

Leave a Reply

Your email address will not be published. Required fields are marked *