PE Prognostication (part 3): Dr Senthi Strikes Back
September 16, 2013
To CT, or not to CT: that is the question:
Whether ’tis nobler in the lungs to suffer
The risks and harms of outrageous investigation
Or to take up probes against DVTs of troubles,
And by sonography end them? To die: to bleed;
No more; and by our tweets to say we end
The head-ache and the thousand natural clots.
(not quite Shakespeare, not quite Hamlet!)
At last – the light at the end of the tunnel! The final installment in the epic PE Prognostication series from Dr Anand Senthi ( @DrSenthi ).
In the first podcast we looked a the history of PE in the literature from the 1960s through to the modern era of Clinical decision rules, D-Dimers, multidetector CTPAs and arrived at today – how do we currently approach the patient with a possible PE. And then we talked about what it means – in the low risk groups what do we know about the treatment of these patients with small, stable PEs?
In part 2 we took a look at Anand’s proposed algorithm – and it was controversial to say the least. The main differences were:
using a higher “test threshold” for CTPA. Somewhere above 4.8%
Using the sPESI score to prognosticate prior to subsequent investigation in order to define a subset of patients whom are potentially going to derive nett harm from the CTPA and subsequent risk of false positivity and uneccessary treatment.
Coming to terms with the concept that anticoagulation may not really be making a big difference to outcomes in simple, haemodynamically stable, small PEs
Then we had a great audio comment from Dr Scott Weingart ( @emcrit ) – he raised a lot of great points – VTE recurrence risk, Well’s, test thresholds, contrast-risk, ECHO and leg US. This is great pre-publication peer review.
In this final episode
Anand responds to Dr Weingart’s comments, it is not always a #FOAMed love in !
we integrate ED-bedside DVT US into the mix with the assistance of Dr Matt Dawson ( @ultrasoundpod ),
we discuss the refined version of Anand’s algorithm.
We look at the ethics of doing a RCT in the current atmosphere
we discuss what such a trial (or trials) might look like
Anand invites you all to get involved
***WARNING: this is a long podcast! 1 hour! But it could be broken into 2 parts – listen firstly to Anand’s response to Scott, then the rest – makes it a bit easier on the brain.
As a special bonus there is a 5 minute literature review by Dr Matt Dawson ( ultrasoundpodcast.com ) on the utility of ED-physician performed DVT US. Short summary: you can do it with good accuracy! DOWNLOAD by Clicking here to learn what bedside US, driving a car and ‘horizontal folk-dancing’ all have in common. Wisdom from the South!
I have really enjoyed going through this process with Anand and seeing the FOAM peer review work as we know it can. I hope that this is the start of a great thing – maybe a trial or two into the previously uncertain area of the low-risk, stable PE patients. PLease, if you are interested in this type of research, or just have questions – get in touch with Anand – either via the comments or on Twitter.
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact