We’re continuing to review the ACEP guidelines and today, we’re going to talk more about the policies of acute venous thromboembolic disease. Please remember, we have three catastrophic blog clots that we have to know if we work in emergency medicine. We have to be masters of heart attack, stroke and PE. We must understand you have big ones and small ones in each category.
What’s a big stroke called? A CVA. What’s a small stroke called? TIA. What’s a big heart attack called? Stemi. What’s a small heart attack called? Non-stemi. Here’s the deal. There are also big PEs and small PEs. If you don’t know the difference, you will get burned because they present so drastically different.
A big PE is like a saddle pulmonary embolism. It affects central circulation, so the patient is really short of breath with abnormal vital signs, but there isn’t any nerve tissue in the lungs, so it doesn’t hurt. They’re really short of breath. Small PEs present very differently. They go peripherally, so only a couple percent of their lung function is affected. Often, they’re not tachycardic and they’re not tachypneic. You have an area of the lung that’s infarcted, but it doesn’t hurt because there’s no nerve tissue.
However, the pleura is a hotbed of nerves. If someone breathes superficially, they have no pain. When they take a deep breath in, they wince and their eyes tear up because it hurts a lot. That’s purely pleuritic chest pain. What I teach at our conferences is that when you have someone with fractured ribs, they’re going to have pain, about four or five out of 10, and when they breathe, it hurts more. But when you have someone with a PE, the pain is only present when they breathe. Purely pleuritic chest pain infers a pulmonary pathology like pneumonia or PE. That’s really important. It’s a life-saving concept.
Diagnosing Acute Venous Thromboembolic Disease
When it comes to ED screening, remember DVTP is a venous heart attack and stroke, our arterials. What’s the best ED screening?
If you have a really low-risk patient, you may use the PERC rules to exclude without further testing. If you use pretest probability, the PERC rules and the patient is under 50, you don’t need to use any other tests to exclude PE.
Low- to Intermediate-Risk Patients
For a patient with a low- to intermediate-risk for PE, you can use the D-dimer to exclude the diagnosis without further testing if they’re older than 50. With a negative D-dimer, you’ve excluded PE to a very high degree of certainty based on ACEP guidelines. Now intervention with anticoagulation is easy. Anticoagulation is recommended for acute PE.
Anticoagulation recommendation for subsegmental pulmonary embolism is a little different. For patients with subsegmental PA, without DVT, anticoagulation should be guided by the patient’s individual risk profile and preferences. There’s a lack of evidence regarding anticoagulation decisions in this situation.
Acute Venous Thromboembolic Disease Disposition
How do we decide what we’re going to do with the patient? As an advanced practitioner working critical access emergency medicine, I’m not sending you home if you’re positive for PE. That’s my personal preference.
ACEP guidelines say that acute PE in selected patients who are at low risk for adverse outcomes (as determined by the simplified PESI score or Hestia criteria) can be discharged with anticoagulation and close outpatient follow up. If you have someone with a low risk for bad outcomes, maybe they can go home on a non-vitamin K, oral anticoagulation as an alternative to low molecular weight heparin and coumadin or a vitamin K antagonist. But as an advanced practitioner, that is above my pay grade.
It really depends on where you practice whether a patient can be discharged and by whom. Understand that if you have a low-risk patient and you use the PERC rules and they’re negative, they can go home. When someone is over 50 with a low- to intermediate-risk, you should really do a D-dimer. Anticoagulation is what you should do.
If you have a small PE and no DVT, we’re not quite sure what to do with them. Some patients will be able to go home. I don’t recommend making that decision without consulting someone else as an advanced practitioner. And some patients with a DVT can be safely discharged on a non-vitamin K antagonist oral anticoagulant.