PV card: PE Severity Index (PESI) score

Do you send some of your low-risk patients with pulmonary embolism home?

This is a controversial issue which warrants a look at risk stratification tools. The primary one used is the validated Pulmonary Embolism Severity Index (PESI) score. In Lancet 2011, the authors looked at whether PESI class I and II (low risk) patients could be managed safely as outpatients. It turns out in their study, regardless of whether their PESI class I and II patients were treated as outpatients and inpatients, all fared equally well from a complications standpoint (recurrent clot, bleeding from anticoagulation).

I like the validated PESI scoring system to risk-stratify patients as low vs high risk for complications. I, however, do caution people to look closely at the exclusion criteria for this study before applying this to all ED patients.

The exclusion filter was so strict that they likely have captured a very narrow and unrealistic scope of patients to be widely applicable. It makes sense from a research standpoint to have these criteria to achieve internal validity but the question is external validity. Two exclusion criteria that struck me as awfully strict were: (1) needing parenteral opioids or (2) active alcohol or drug abuse.

Bottom line

For me, this study alone seems not have enough external validity to decide about the decision to treat PE patients as inpatient vs outpatient. Although I think that ultimately some can be managed as outpatients, I’d like to see more studies.

PV Card: PESI Score for Pulmonary Embolism

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See other ALiEM (PV) Cards.

By Michelle Lin, MD|2021-10-08T09:35:48-07:00Nov 17, 2012|ALiEM Cards, Cardiovascular, Pulmonary|

Take the quiz: Do you know your antihypertensive agents?

Identify the antihypertensive agent:

1. Rapid acting systemic and coronary artery vasodilator with minimal effects on cardiac conductivity or inotropy. Well studied in pregnancy. Caution in patients with left ventricular failure, liver cirrhosis

Answer: Nicardipine

2. Predominantly dilates the venous system. Useful in patients with cardiac ischemia, pulmonary edema, or congestive heart failure. Caution in patients with right ventricular failure

Answer: Nitroglycerin

3. Drug of choice in eclampsia, pre-eclampsia, and aortic dissection. Contraindicated in patients with congestive heart failure and heart block

Answer: Labetalol

4. Decreases peripheral vascular resistance and increases collateral coronary blood flow in an uncontrolled and unpredictable manner and may result in serious complications. Drug of choice during pregnancy

Answer: Nifedipine

5. Direct arterial vasodilator that increases cardiac output and heart rate (Reflex response). Patient may develop lupus like syndrome. Not to be used as first line in the ED

Answer: Hydralyzine

6. Arterial vasodilator that delays atrioventricular conduction and has a negative inotropic effect

Answer: Verapamil

7. Rapid onset of effect after oral administration (30 mins) with little change in cardiac output or reflex tachycardia. Adverse effect may include cough, angioedema. Toxic during first trimester.

Answer: Captopril

8. Only for patients with subarachnoid hemorrhage. Not to be given IV only PO or NG tube

Answer: Nimodipine

9. The only parenteral angiotensin-converting enzyme inhibitor. May cause azotemia in older patients after MI

Answer: Enalapril

10. Oral or transdermal decreases peripheral vascular resistance. May cause sedation and bradycardia

Answer: Clonidine

11. Used in patients who are volume overloaded but not in patients who are hypertensive and volume depleted

Answer: Diuretics

12. Drug of choice for pheochromocytoma, MAOI crisis, and cocaine overdose

Answer: Phentolamine

Reference:
1. Richard S. Irwin, James M. Rippe. Manual of Intensive Care Medicine; 4th ed
2. Marx: Rosen’s Emergency Medicine, 7th ed (Chapter 82- Hypertension: Richard O. Gray)

By Javier Benitez, MD|2016-11-11T11:52:01-08:00Nov 14, 2012|Cardiovascular|

Trick of the Trade: Searching for Comments to a Published Article

One day back in 2005 during my PGY-1 pharmacy practice residency, I remember a conversation with my residency director. He was a Surgical/Trauma ICU pharmacist. There had been a recent article published (I think it may have been one linking ‘tight’ glucose control to decreased mortality in ICU patients). Funny how times change…

Anyway, he mentioned all of the ‘discussion’ surrounding the article in terms of comments submitted to the journal. It was my first introduction to the idea that published literature could be challenged through an avenue provided by the journal.

Just this past week during EM residency journal club, we were discussing the recent Etomidate/Sepsis Meta-Analysis published in Critical Care Medicine (more to come on that soon in another post). I mentioned to my group how one could search for submitted comments. Most seem surprised to learn this trick of the trade.
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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:43:15-08:00Nov 13, 2012|Medical Education, Tricks of the Trade|

New video series for med students: The Patwari Academy

Similar to Salman Khan of the Khan Academy, which is famous for “flipping the classroom”, Dr. Rahul Patwari is a one-man innovating machine at Rush University’s Department of Emergency Medicine. He has been creating digital whiteboard “chalktalks” on common EM conditions for the past year, which target the senior medical student. These 2-15 minute videos are way too amazing not share with the EM community of learners. I bet these would be really great supplemental learning material for EM medical students everywhere.

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By Michelle Lin, MD|2026-06-16T16:02:24-07:00Nov 12, 2012|Patwari Videos|

Trick of the Trade: Persistent paracentesis leakage

Dr. Matt Borloz (Carilion Clinic) recently emailed me his recent trick in fixing a persistently leaking paracentesis site. Read about his experience:

A patient with advanced alcoholic cirrhosis with ascitic fluid leaking from a paracentesis puncture site from a procedure done 2 days prior. Dermabond had initially been applied post-procedure, but it had come loose, and ascitic fluid had been saturating dressing after dressing.

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By Michelle Lin, MD|2016-11-11T18:43:16-08:00Nov 6, 2012|Gastrointestinal, Tricks of the Trade|

Mythbuster: Urgent dialysis following IV contrast?

Have you ever had to promise the radiologist that you would arrange emergent dialysis for your end-stage renal disease (ESRD) patient after receiving IV contrast?

This myth is even perpetuated in the field of nursing. In fact, what prompted this post was overhearing this very topic discussed between a nurse and a recent graduate nurse trainee.
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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2019-02-19T18:47:01-08:00Oct 31, 2012|Renal, Tox & Medications|

Trick of the Trade: Universal precautions for your iPad

iPads are increasingly being used in medical education in a variety of arenas, including the classroom, the bedside, and small group workshops.

I recently taught in a procedures lab with unembalmed cadavers at UCSF’s new anatomy lab (on the 13th floor of the hospital with spectacular views of San Francisco and the Golden Gate Bridge). Everyone was gowned up from head to toe using universal precautions. But wait, what about my iPad? How can I use it to teach at the “bedside” about arthrocentesis?

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By Michelle Lin, MD|2018-10-28T21:48:52-07:00Oct 30, 2012|Tricks of the Trade|