To Odin..........Plz Explain - drbkc

[ArchivalUser]

hi odin,

sorry to bother u.
plz check below the link..que posted by dream dr.

http://www.usmleforum.com/showthread.php?tid=468659

can u plz provide proper explanation abt PE mgt.when we shud give anticogulants before diagnostic procedure?? what cases we shud do diagostic test first before tx??

Thanks in Advance..it will helpful for everyone..

[ArchivalUser]

For PE we start with therapy even before dg only in case of massive PE-begin IV UFH (unfractioned heparin) and transfer to ICU. Here, first treat. You know, the general rule, when patient is unstable, first treat and stabilize.
For submassive and small PE when the patient is stable we use the algorithm of clinical decision (Wells score): if less than 4, first D-dimer, and if D-dimer positive, then CT scan or V/Q scan (in renal insufficiency, anaphylaxis to contrast, pregnancy); if Wells score>4, directly spiral CT scan. So, here first dg, then treat.
Also, for massive PE we initiate UFH (and if no contraindications for thromblytics-stop UFH and give t-PA) while for non-massive, it goes with LMWH.

[ArchivalUser]

HOW TO KNOW EMBOLI IS SMALL OR BIG WITH OUT INVESTIGATION?

[ArchivalUser]

Thanks a LOTTtttttttttt odin..now i got clear concept..

i didnt know abt wells score ..now i got it from ur explanation..


The Wells score:[10]

clinically suspected DVT - 3.0 points
alternative diagnosis is less likely than PE - 3.0 points
tachycardia - 1.5 points
immobilization/surgery in previous four weeks - 1.5 points
history of DVT or PE - 1.5 points
hemoptysis - 1.0 points
malignancy (treatment for within 6 months, palliative) - 1.0 points

Traditional interpretation

Score >6.0 - High (probability 59% based on pooled data[12])
Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data[12])
Score 4 - PE likely. Consider diagnostic imaging.
Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.


thank u very much..

[ArchivalUser]

sorry ,i missed some lines..

traditional interpretation

Score >6.0 - High (probability 59% based on pooled data[12])
Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data[12])
Score 4 - PE likely. Consider diagnostic imaging.
Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.

[ArchivalUser]

oops.. i cudnt post..


if score low probability

[ArchivalUser]

To pursuit-of-99: There are clinical criteria to evaluate PE (Braunwald Cardiology):
1. Massive PE: hypotension or extreme hypoxemia with poor tissue perfusion, multiorgan failure plus right or left main pulmonary artery thrombus or œhigh clot burden
2. Submassive PE: Hemodynamically stable but moderate or severe right ventricular dysfunction or enlargement
3. Small to moderate PE: Normal hemodynamics and normal right ventricular size and function
This doesn't mean that we don't need work-up, it gives just a hint of how severe the PE is and it is part of PE risk stratification

[ArchivalUser]

ok tnx odin...

[ArchivalUser]

i disagree with this............

1st step in PE is modified Wells score............if high clinical suspicion (score more than equal to 4) of PE ........then anticoagulate 1st if not at high risk of bleeding ......if massive PE or morbid obesity or renal failure then IV UFH if not then SQ LMWH doc

2nd step wud be either CT or VQ.........if low suspicion (

[ArchivalUser]

hmmmm........it did not post my complete explanation......i think it does not let us use less than sign

i disagree with this............

1st step in PE is modified Wells score............if high clinical suspicion (score more than equal to 4) of PE ........then anticoagulate 1st if not at high risk of bleeding ......if massive PE or morbid obesity or renal failure then IV UFH if not then SQ LMWH doc

2nd step wud be either CT or VQ.........if low suspicion ( modified Wells less than 4) then preceeded by D dimer if D dimer less than 500 then PE is excluded.......if high suspicion or D dimer more than 500 then CT preferred esp if CXR is abnormal or if no C/I ( contrast anaphylaxis, renal failure, morbid obesity, and pregnancy)

3rd step .........interpret results.......if VQ used then it wud be diagnosed as high, medium or low probability scans........this has to be combined with traditional wells score (high , medium and low clinical suspicion)......

if low low......then PE excluded
if high high ..........then PE diagnosed
if any other combo..........then CT or serial dopplers of legs

if CT........then if positive then PE if negative then PE excluded.......but CT wont detect PE in small segmental vessels

SO WE ALWAYS START RX ie ANTICOAGULATION BEFORE IF CLINICAL SUSPICION OF PE IS HIGH BASED ON MODIFIED WELLS SCORE MORE THAN 4.........IF NO RISK OF INCREASED BLEEDING..........AS THE RISK BENEFIT RATIO TOTALLY JUSTIFIES IT......AND IF THE TEST IS NEGATIVE ANTICOAGULATION CAN BE DISCONTINUED IMMEDIATELY

WOULD WELCOME EVIDENCE BASED FACTS TO SUPPORT OR CONTRADICT THIS!!

best of luck!!