just to scare you: saddle PE that didn’t read the textbook

23 Jan

case report in Annals of Emergency Medicine by Hennessey et al.:

PERC Rule = clinical decision rule used to identify patients low-risk for PE, where D-dimer is unnecessary

  • Age <50
  • Pulse <100
  • 02 sat >94%
  • no unilateral leg swelling
  • no hemoptysis
  • no recent trauma/surgery
  • no previous PE/DVT
  • no exogenous estrogen (e.g. OCPs)

if all 8 negative = low risk

may miss 1-2% of PEs, but suggested these would be low mortality/low clot burden patients

 

CASE HIGHLIGHTS:

42 yo F

chief complaint: chest pain, x 1 day

relieved with Pepto x2, recurred overnight, came to ED

CP 8/10, non-exertional, non-pleuritic, pressure

minimal SOB with speaking, no DOE

 

PMHx: HTN, anemia, etc.

No hx DVT, no OCPs, family hx unremarkable

 

VS 115/73, P 92, AF, 100%/RA

EKG NSR

Labs unremarkable, troponin negative

low risk Well’s, PERC negative

 

resident ordered D-dimer prior to attending chat

D-dimer resulted at upper limit of lab testing ability (VERY HIGH)

CTA: multiple L central & subsegmental PEs, large R saddle embolus

 

inpatient Echo: nml, no RV enlargement

 

5 wk later, returned to ED for CP: INR therapeutic, resolution of PE’s on CTA

 

10-SECOND TAKEAWAY:

  • clinical decision rules are low-risk, not NO risk
  • accept some tiny risk of missing something when you use these, at the benefit of not irradiating everyone
  • good luck

 

References: case report; PERC rule MDCalc.com; Well’s Criteria MDCalc.com; picture

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