1. Morning report
7/10/18
VA Team 1

2. HPI
65 yo male with PMHx of HTN, HLD, and COPD presented to the ED from OLF secondary to worsening shortness of breath. Patient reports he’s been having difficulty breathing for the past two weeks. He reports sharp pleuritic chest pain during deep inhalation as well as chest pain following coughing spells. He denies any radiation of the pain to his back, arm, or jaw. Denies experiencing anything like this before. Reports nothing has made it better. He also reports blood tinged sputum for the past three days.
After further discussion patient reveals he recently drove to visit his son in Denver, CO a little less than a month ago. Reports bilateral lower extremity edema for the past two weeks and new onset redness of his left leg.
He denies headache, dizziness, palpitations, fevers, nausea/vomiting, new onset numbness/weakness/tingling

3. History
PMH: HTN, HLD, COPD, chronic back pain, tobacco dependence, cataract, glaucoma
PSH: Hemorrhoidectomy
FamH: Reports no significant family history
Allergies: Penicillin
SocH
Tobacco: 30 pk/yr history, quit smoking 4 years ago
Alcohol: Denies
Drugs: Denies
Reports his chronic back pain keeps him from doing a lot of activity
Meds: Asa 81mg, Ketotifen 0.25%, latanoprost 0.005%, Cholecalciferol 5000U daily, Cyanocobalamin 2,500 weekly, Fexofenadine 180mg

4. Objective VS: Temp: 96.5F; BP 102/77; HR 94; RR 22; O2 95
General: alert and oriented, appears stated age, lying in bed in moderate distress
HEENT: Normocephalic, EOMI, PERRLA, mucosa moist and non erythematous
Cardiovascular: Regular rate, regular rhythm, no murmur/rub/gallop
Respiratory: Diminished lung sounds bilaterally, no wheezes/rales/rhonchi, patient on 2L NC oxygen
Abdomen: Normoactive BS x4, soft, non tender to palpation, dullness to percussion
Extremities: Radial and DP +2/4, 2+ pitting edema bilaterally up to ankle, erythema of left lower extremity from ankle to shin, tender to palpation bilaterally
Skin: warm, dry, erythema of LLE from ankle to shin

5. Differential?

6. Labs/Imaging ABG Venous duplex ultrasound of lower extremities
pH 7.51 CO
O2 68.0
Venous duplex ultrasound of lower extremities
DVT in left lower extremity
CTA chest
Bilateral PE with evidence of right heart strain
EKG
Right axis deviation and T wave inversion
Echo
Evidence of right heart strain - McConnell’s sign
CMP
Na 134
K 3.5
Cl 95
CO2 31
Glucose 113
BUN 41
Creatinine 1.55
CBC
WBC 6.3
Hgb 13.8
Plt 110
Others
Troponin < 0.03
CKMB 1.3
BNP 284
D-Dimer 22

7. CT showed bilateral pulmonary emboli with right heart strain pattern.
CT showed bilateral pulmonary emboli with right heart strain pattern.

8. Echo
EF 55-60% .Right ventricle is dilated with reduced movement of lateral free wall potentially consistent with McConnells sign (seen in setting of acute PE).

9. Classification of PE Massive Submassive Low Risk
Hemodynamically unstable with evidence of right ventricular heart strain
Hemodynamically unstable PE is that which results in hypotension. Hypotension is defined as a systolic blood pressure <90 mmHg or a drop in BP great than or equal to 40mmHg for 15 minutes or more
Submassive
Hemodynamically stable with evidence of right ventricular heart strain
95% of patients will appear hemodynamically stable at first encounter and not considered to be high risk
Low Risk
No evidence of right ventricular heart strain

10. Diagnostic Work-up
If hemodynamically stable you begin with assessment of clinical or pre test probability that patient has a PE
Wells Criteria, revised Geneva, PERC
D-dimer with low pre test probability. Always do age adjusted D dimer for patients older than 50.
If high clinical probability of a PE, patients go straight to imaging
CTA preferred over VQ scan due to high proportion of nonconclusive results in VQ scan
V/Q SPECT new diagnostic tool that shows promise of improving diagnostic performance
If hemodynamically unstable perform bedside echo or venous compression ultrasound
Use of the PESI score has been validated as a risk stratification tool when deciding if patients are at risk of an adverse outcome if treated outpatient

11. ADJUST-PE Study
Multicenter, prospective study evaluating 3,346 patients with suspected PE
Patients with normal age-adjusted D-dimer (age X 10, above 50) did not undergo CT PE.
Left untreated and followed for 3 months
Using age-adjusted (instead of the standard 500 µg/l D-dimer increased the number of patients that could be excluded from 6.4% to 30% in those 75 yo or older without significant increase in VTE at follow-up.

12. Pulmonary Embolism Severity Index (PESI) and Simplified (PESI)

15. Treatment Anticoagulation Thrombolysis Fluids Pressors IVC Filter
NOAC therapy (apixaban, dabigatran, rivaroxaban, edoxaban)
Acute VTE anticoagulation for a minimum of 3 months
For longer term anticoagulation assess if it was provoked vs unprovoked DVT as well as patient’s clinical picture
Thrombolysis
In patients with hemodynamic instability, not those with intermediate risk
Risk of major hemorrhage
Use of catheter directed, ultrasound assisted thrombolysis at qualified centers
Fluids
Pressors
IVC Filter
Patient population: absolute contraindication to anticoagulation, major bleeding events during acute phase, recurrent PE that failed anticoagulation therapy

16. EINSTEIN-PE
Randomized, open-label, event-driven, noninferiority trial involving 4832 patients with PE +/- DVT.
Primary efficacy outcome was symptomatic recurrent PE.
50 events Rivaroxaban (2.1%)
44 events enoxaparin/vitamin K antagonist (1.8%), hazard ratio 1.2
Primary safety outcome was major or clinically relevant bleeding
10.3% rivaroxaban, 11.4% standard therapy
Rivaroxaban was noninferior to standard therapy for initial and long term therapy

17. Sources
Konstantinides, Stavros V., MD, PhD, Stefano Barco, MD, Mareike Lankeit, MD, and Guy Meyer, MD. "Management of Pulmonary Embolism." Journal of the American College of Cardiology  /536 (2016): Print.
Taylor MD, Kabrhel MD. Overview of pulmonary embolism in adults. UpToDate. Waltham, MA: UpToDate Inc. Internet. (Accessed on July 9, 2018)
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