Suspected PE patients may be getting needless CTs
Suspected PE patients may be getting needless CTs
Guidelines aren't being followed
Many pulmonary embolism (PE) patients are getting multi-detector CT (MDCT) scans who don't need them, while others need them and don't receive them, according to new research. Although current accepted clinical practice says that patients with a low clinical suspicion for PE should receive an MDCT scan only if D-dimer testing is positive, researchers found MDCT scans were given to 7% of patients with negative D-dimer results. In addition, 42% of patients with suspected PE and a positive D-dimer exam did not get an MDCT scan.1
At times, PE patients "are caught in the chest pain net," says Lillian Jones, RN, an ED nurse at Parkland Health & Hospital System in Dallas. "I can recall cases of physicians going down the chest pain or pneumonia pathway, than turning around and doing a PE work-up."
For this reason, "ED nurses need to put PE on their list to think about," says Jones. "All too often, chest pain, shortness of breath, or cough conjure up in most nurses' minds myocardial infarction or pneumonia. And they don't investigate further."
When assessing a patient for PE, "the rate and depth of respiratory status is key," according to Christopher Manacci, RN, MSN, a member of the critical care transport team at the Cleveland Clinic. "The patient can present with tachypnea and/or dyspnea."
Ask these questions, says Manacci: Is the patient prone to blood clots? Does he or she have a current deep vein thrombosis (DVT)? Is the patient a smoker? Has there been a long period of inactivity, such as a extended flight? Is the patient taking birth control pills?
"Any of these factors can increase the risk for PE," says Manacci. He gives the example of a 34-year-old smoker who is taking birth control pills and dyspnea. In this case, "the ED nurse needs to identify the correlation between the patient's symptoms and history. Evaluate the onset of symptoms. PE is generally abrupt onset."
10 risk factors to look for
Consider these risk factors at triage, says Melissa Gaines, RN, education clinical coordinator for emergency services at Sts. Mary and Elizabeth Hospital in Louisville, KY:
- having an inherited conditions that cause increased risk for blood clotting;
- having restricted or slow blood flow in a deep vein, due to injury, surgery, or having to stay in bed for a long time;
- having cancer and its treatment;
- having medical conditions such as varicose veins;
- sitting for a long period of time, such as car or airplane trips;
- during pregnancy and during the six-week period after delivery;
- being over age 60;
- being overweight or obese;
- taking birth control or hormone replacement pills;
- having a medical condition that requires a central venous catheter.
"The more risk factors you have, the greater your chance for developing DVT and pulmonary embolism," says Gaines.
Jones says to watch for these four red flags for PE:
- any unexplained tachycardia associated with shortness of breath. "This is my key standout symptom," says Jones. "Once you have eliminated all possible causes for the tachycardia, think PE"
- new onset of atrial fibrillation;
- dyspnea with clear breath sounds;
- any unexplained anxiety. "Patients often look anxious and say that they feel they cannot get enough air in," says Jones.
Along with this, Jones says to "look at the big picture. Do a body scan and check for obesity, lower extremity edema, and peripheral vascular disease."
Reference
- Corwin MT, Donohoo JH, Partridge R, et al. Do emergency physicians use serum D-dimer effectively to determine the need for CT when evaluating patients for pulmonary embolism? Review of 5,344 consecutive patients. AJR Am J Roentgenol 2009; 192:1,319-1,323.
Sources
For more information on assessment of pulmonary embolism in the ED, contact:
- Melissa Gaines, RN, Emergency Services, Sts. Mary & Elizabeth Hospital, Louisville, KY 40215. Phone: (502) 361-6740. Fax: (502) 367-3340.
- Lillian Jones, RN, Emergency Services, Parkland Health & Hospital System, Dallas. Phone: (214) 590-1144. Fax: (214) 590-2781. E-mail: [email protected].
Don't waste any time if PE is suspected If you suspect pulmonary embolism (PE), support your patient with supplemental oxygen or a bag valve mask if necessary, says Christopher Manacci, RN, MSN, critical care transport team at the Cleveland Clinic. "Also, obtain a 12-lead EKG to ensure other causes of clinical symptoms are ruled out," he says. "Waiting for a formal diagnosis of PE after a CT scan can lose time." Instead, Manacci says to "prepare the second level of intervention, so once medications are ordered, they can be initiated in a timely fashion." Lillian Jones, RN, an ED nurse at Parkland Health & Hospital System in Dallas, says to anticipate the need for a sonogram, a ventilation/perfusion lung scan, a chest CT/angiography, and initiation of your ED's adult venous thromboembolism weight-based heparin protocol. "Our nurses have the ability to initiate care on patients in order to facilitate timely interventions and turnaround times," says Jones. If PE is suspected, the ED's standing orders for chest pain are used, as follows:
The necessary labs for PE are added by verbal or written orders. "We would need to talk to the ED physician about ordering a D-dimer, platelet count, and arterial blood gas, along with our initial lab draw," says Jones. |
Consider PE if chest pain is 'unstable' Melissa Gaines, ED educator for Sts. Mary and Elizabeth Hospital in Louisville, KY, says that ED nurses should be aware if a patient presents with chest pain, the pain may be "unstable, such as in an occurring and relieving pattern." With pulmonary embolism (PE), "oxygen saturation readings may drop during periods of increased shortness of air or chest pain, she says. "The saturation will resolve to the high 90s once the airway improves or chest pain subsides." |
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