Give anticoagulants early in ED: You'll reduce PE mortality rates

Would your acute pulmonary embolism (PE) patient always receive anticoagulants in the ED? Or does this occur only after the patient is upstairs on the floor? Your answer might impact that patient's outcome.

Giving the drug in the ED decreases mortality rates, according to research from the Rochester, MN-based Mayo Clinic, which studied 400 ED patients diagnosed with acute PE by CT angiography.1 Patients who received heparin in the ED had lower in-hospital and 30-day mortality rates, compared to those given heparin after admission.

"PE should be included in the differential diagnosis of most cases of acute dyspnea presenting to the ED," says Timothy I. Morgenthaler, MD, one of the study's authors and associate chair of the Department of Medicine at Mayo Clinic. "To the extent that PE is thought possible, the evaluation should not be delayed. If PE is thought likely, treatment ought to be started when it is thought of, rather than waiting for all evaluations and admission to be completed."

Samuel Z. Goldhaber, MD, director of the VTE Research Group in the Cardiovascular Division of Boston-based Brigham and Women's Hospital, says, "ED nurses have unique opportunities to reduce the death rate from acute pulmonary embolism." First, you might suspect PE when others don't. "Other ED providers may have been led astray and are working to rule out myocardial infarction or treat congestive heart failure," says Goldhaber. "Remind other members of the care team if PE has been inadvertently overlooked."

Goldhaber says that a D-dimer blood test usually should be obtained if the diagnosis of PE is "a reasonable possibility."

Secondly, as soon as the diagnosis of PE is established on an imaging test, you should insist that full dose anticoagulation be ordered right away, Goldhaber says. He gives these three options for this:

— intravenous (IV) unfractionated heparin bolus followed by continuous infusion;

— full dose low molecular weight heparin, such as enoxaparin 1 mg/kg every 12 hours or dalteparin 100 U/kg every 12 hours in patients with normal renal function,

— full dose fondaparinux (5 mg for weight < 50 kg, 7.5 mg for weight 50 to 100 kg, or 10 mg for weight > 100 kg in patients with normal renal function.

"Don't wait for the 'floor team,' to whom the patient will eventually be admitted, to administer the anticoagulant," says Goldhaber. "With hospitals being so overcrowded these days, the ED nurse may have to continue ensuring adequate anticoagulation for 12, 24, or even 36 hours until a bed becomes available upstairs."

Order sets speed care

Because PE patients present with a multitude of chief complaints, ED nurses use nursing protocol orders for some of these symptom presentations, such as chest pain and dyspnea, to speed care. [The protocols used by ED nurses are included.]

Caroline Lynn, BSN, RN, FNE, SANE, shift coordinator for the ED at Clarian West Medical Center, Avon, IN, says, "With our protocol orders in place, patients care is expedited based upon the chief complaint."

In the case of a 57-year-old white female with sudden stabbing right-sided chest pain with radiation to the right back region, the ED nurse quickly implemented standing orders for chest pain. "The pain was associated with shortness of breath while at rest," says Lynn.

The patient's medical history included Parkinson's disease and limited mobility. Her heart rate was 120, with all other vital signs stable. ED nurses performed these interventions:

— An EKG was completed within 10 minutes.

— The patient was placed on 2 liters of oxygen per nasal canula and placed on a cardiac monitor.

— A 20 g peripheral IV catheter was started in the antecubital region.

— Blood work was obtained, including a cardiac troponin level and prothrombin time/international normalized ratio (PT/INR).

"Nitroglycerin and morphine were immediately given for chest pain, with relief noted. Heart rate decreased to 90," says Lynn. "The EKG showed no abnormalities. Lab studies were normal."

Based on this information, enoxaparin 1mg/kg was given subcutaneously. A chest CT with contrast was ordered, and a PE was diagnosed. The patient was admitted for continued anticoagulopathy treatment with enoxaparin and warfarin.

Be proactive

If a PE is suspected, but not yet diagnosed, ED nurses take these actions immediately:

— A large bore IV is placed in the antecubital region.

— At the time of the IV start, blood tubes are drawn for routine cardiac/pulmonary labs, including a PT/ INR.

— Enoxaparin generally is administered at 1mg/kg subcutaneously in the ED.

— A chest CT with contrast is ordered.

"The ED nurse streamlines the patient care process by completing a thorough and ongoing nursing assessment," says Lynn.

ED nurses quickly identified the possibility of PE based on a 27-year-old man's clinical presentation and history. He presented with a chief complaint of severe right lower leg pain, and reported a four-hour car trip a few days earlier. "A deep vein thrombosis was diagnosed to right femoral vein per ultrasound," says Lynn.

Based on these findings, a routine chest CT with contrast was performed, despite the patient's denial of any chest pain or dyspnea. PE was diagnosed.

Enoxaparin was administered at 1mg/kg subcutaneously and continued as inpatient therapy with warfarin. "The patient was placed on a cardiac monitor and closely watched for any clinical changes or deterioration," says Lynn.

Reference

  1. Smith SB, Geske JB, Maguire JM, et al. Early Anticoagulation is associated with reduced mortality for acute pulmonary embolism. Published online before print Jan. 15, 2010. Doi: 10.1378/chest.09-0959.

Sources

For more information on improving care of pulmonary embolism patients in the ED, contact:

  • Samuel Z. Goldhaber, MD, Director, VTE Research Group, Cardiovascular Division, Brigham and Women's Hospital, Boston. Phone: (857) 307-1932. E-mail: sgoldhaber@partners.org.
  • Caroline Lynn, BSN, RN, FNE, SANE, Shift Coordinator, Emergency Department, Clarian West Medical Center, Avon, IN. Phone: (317) 217-2789. E-mail: clynn@clarian.org.
  • Timothy I. Morgenthaler, MD, Department of Medicine, Mayo Clinic, Rochester, MN. Phone: (507) 284-3764. Fax: (507) 266-4372. E-mail: tmorgenthaler@mayo.edu.

Clinical Tip

Don't overlook PE in these patients

Pulmonary embolism (PE) is less likely to be considered in elderly patients with multiple other cardiopulmonary co-morbidities, says Timothy I. Morgenthaler, MD, associate chair of the Department of Medicine at Mayo Clinic.

"Unfortunately, these are patients who are also at risk for PE, so the diagnosis should probably be more liberally considered," Morgenthaler says.