Pulmonary Embolism: Next Generation

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This talk introduces the concept of a new generation of pulmonary embolism (PE). What was once considered a deadly disease process now carries a mortality rate of <3%, which may be driven by overtesting as well as overdiagnosis. This talk will explore this phenomenon and current evidence-based approaches to the evaluation and treatment of PEs.

Health & Medicine

Lauren Westafer, DO, MPH, MS
@LWestafer
PE
NEXTGENERATION

diagnosis of less severe
(and nonexistent)
PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

2004 2009
PEs/10,000EDvisits
diagnosis of less severe PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

2004 2009
PEs with RV strain
PEs/10,000EDvisits
diagnosis of less severe PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

2004 2009
no RV strainPEs with RV strain
PEs/10,000EDvisits
diagnosis of less severe PEs
Schissler AJ. PLoS One. 2013;8(6):e65669.

overtested
overdiagnosed
overtreated
PE
NEXTGENERATION

CTPA yield
CTPA yield
9-25%
NICE recommendations
target 15.4 - 30%

CTPA yield
2-10%
10-17%
9-25%
17%
10-31%

CTPA yield
2-10%
10-17%
9-25%
39%
17%
10-31%

risk stratiﬁcation
harm of testing > beneﬁt

risk stratiﬁcation
harm of testing > beneﬁt
probability of PE < 1.8%

risk stratiﬁcation
Wells
PERC
age adjusted d-dimer

YEARS
risk stratiﬁed d-dimer
van der Hulle T et al. Lancet 2017;390(10091):289–97.

YEARS
no hemoptysis
no DVT
PE is most likely diagnosis
d dimer cut off of 1000 ng/mL if….
van der Hulle T et al. Lancet 2017;390(10091):289–97.
Kabrhel C et al.Acad Emerg Med. 2018;25(9):987–94.

YEARSin pregnant patients!
van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.

Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/

Murphy N, et al.. BJOG. 2015;122:395–400.Available from: http://dx.doi.org/
NORMAL d-dimer in pregnancy

YEARSin pregnant patients!
van der Pol LM et al. N Engl J Med. 2019;380(12):1139–49.
prevented imaging in
65% 1st trimester
46% 2nd trimester
32% 3rd trimester

risk stratiﬁcation
Wang RC et al.Ann Emerg Med. 2016;67(6):693–701.
Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76.
Goehler et al.Acad Radiol 2018;06519:1–7.

risk stratiﬁcation
CTPA yield
Wang RC et al.Ann Emerg Med. 2016;67(6):693–701.
Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76.
Goehler et al.Acad Radiol 2018;06519:1–7.

risk stratiﬁcation
we override it in 25-96% of patients*
CTPA yield
Wang RC et al.Ann Emerg Med. 2016;67(6):693–701.
Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76.
Goehler et al.Acad Radiol 2018;06519:1–7.

risk stratiﬁcation
we override it in 25-96% of patients*
(mostly in the US)
CTPA yield
Wang RC et al.Ann Emerg Med. 2016;67(6):693–701.
Buchanan I, et al.Acad Emerg Med 2017;24(11):1369–76.
Goehler et al.Acad Radiol 2018;06519:1–7.

false + CTPA for PE
5-26%Gimber LH et al. . Perm J [Internet] 2009;13(4):4–10.
Costantino G et alAm J Emerg Med [Internet] 2009;27(9):1109–11.
Ruiz Y et al. Eur Radiol 2003;13(4):823–9.
Ghanima et al. Acta radiol 2007;48(2):165–70.
Hutchinson et al. Am J Roentgenol 2015;205(2):271–7.

k=0.21
Ruiz Y, et al. Eur Radiol 2003;13(4):823–9.
subsegmental clots
CTPA interrater reliability

it ain’t just subsegmental clots!
k=0.4 - 0.8
Ruiz Y, et al. Eur Radiol 2003;13(4):823–9.
Chartrand-lefebvre C, . Detection : Experience. 1999;(January).
segmental

the problem with false + PEs…
unnecessary anticoagulation

the problem with false + PEs…
unnecessary anticoagulation
bleeding

the problem with false + PEs…
“history ofVTE”

“i’m short of breath and have
pneumonia”

“i sprained my ankle and i’m
tachycardic”

subsegmental clots
Kearon. Chest. 2016.
Wolf SJ, et al.Ann Emerg Med 2018;71(5):e59–109.
without DVT
consider treatment based on individual risk factors

PESI class I/II
outpatient treatment
sPESI 0
Hestia criteria
Simková I, et al. Eur Heart J 2014;35(43):3033–73.
Kearoon. Chest 2016
Davies C et al. BMJ Open Respir Res 2018;5(1):e000281.

PEovertested
overdiagnosed
overtreated
understand risk of false positives of CTPA
testing rationally
and treating conservatively

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In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis. Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings. The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety. 9. Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury. 8. Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest? 7. Then, can a machine learning algorithm reduce hypotensive severity? 6. In mechanically ventilated patients, is an approach of non sedation superior to light sedation? 5. Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes? 4. Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality? 3. Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients? 2. Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients? 1. Also, will being conservative with oxygen in patients with ARDS improve outcomes? Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes.

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Coda Change

From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure. Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function. Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange. In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used. CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients. Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places. Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support. Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant. From #CodaZero tune in to a quick, sharp & informative talk by Alex Rowell on Acute Liver Injury.

Advanced support of Acute Liver Injury

Coda Change

Surgical considerations in the injured spine patient

Coda Change

Echo in Cardiac Arrest by Behny Samadi From #CodaZero Live, Behny explains the importance of Echo and lists some of the ways in which Echo can help us during a cardiac arrest. It is more than we think! Echo is a quick, easy and simple tool, making it invaluable in many situations including cardiac arrests. It is a bedside test that is non invasive and painless for the patient. It is easily taught to any doctor or nurse and done in real time at the bedside. It can be used to guide and inform management and treatment... so why isn't everyone embracing Echo? Behny challenges us to consider another bedside tool which compares to the effectiveness and usefulness of Echo. Furthermore, in the chaos of cardiac arrests, Echo can help to exclude some of the 4Hs & 4Ts. It can help to check the rhythm, check the quality of compressions and assess for post-resuscitation care. It is an invaluable tool in managing patients suffering from cardiac arrest. Behny suggests that the focused 2D echo is our generations stethoscope. We need to open our minds and embrace the capabilities of Echo and challenge each other to learn how to effectively utilise this tool in times that matter. Tune in to a fascinating podcast by Behny Samadi on the value of Echo in Cardiac Arrest. As a self-confessed Echo enthusiast - Behny is here to share her knowledge on the benefits of Echo. For more like this, head to our podcast page. #CodaPodcast

Echo in Cardiac Arrest

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