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Benefiting from Pulmonary Embolism Response Teams

Benefiting from Pulmonary Embolism Response Teams

Patients with massive or sub-massive pulmonary embolisms (PEs) often face poor survival odds—not necessarily due to the severity of their disease, but because their treatment is often suboptimal or treated too conservatively. This patient population is critically ill but often misdiagnosed as having acute myocardial infarction (MI). These factors may contribute to PE being one of the most common causes of death in the United States. In order to reverse high mortality rates associated with PE, the Detroit Medical Center created a PE Response Team (PERT) in 2014. The team was designed to treat PE patients as quickly as possible using advanced modalities, including ultrasound-accelerated, catheter-directed thrombolysis. For a study published in Cath Lab Digest, Mahir Elder, MD, and colleagues assessed more than 1,500 cases of patients hospitalized with acute PE. “We found that patients who were treated with standard systemic thrombolysis had higher in-hospital mortality and intracranial hemorrhage than those who were treated with catheter-directed thrombolysis,” says Dr. Elder. “To date, the 250 patients who have been treated by our PERT team—called Clotbusters—have a 10% mortality rate, whereas patients at our institution with massive or sub-massive PE who received systemic tPA or heparin have a 60% mortality rate.”   All About PERT The Detroit Medical Center PERT includes interventional cardiologists, nurses, cardiovascular technologists, and radiation therapists. Initially, referrals to Clotbusters came from emergency physicians with hypotensive patients who needed immediate treatment. “Now, pulmonologists, oncologists, and surgeons with ICU patients who develop PEs activate the pager that mobilizes our team 24 hours per day, 7 days per week,” says Dr. Elder. “We also get referrals from many emergency departments...
A Different Strategy to Help Prevent VTE in Trauma Patients

A Different Strategy to Help Prevent VTE in Trauma Patients

Venous thromboembolism (VTE)—consisting of pulmonary embolism (PE) and DVT—is one of the most common and deadliest complications experienced by trauma patients admitted to hospitals. According to recent estimates, trauma is the leading killer of young people in the United States. Other studies suggest that at least 100,000 people die from PE alone every year. In light of the incidence of these events, the AHRQ recently placed interventions to improve VTE prophylaxis on its top 10 list of patient safety practices that are strongly encouraged. Changing the Approach of VTE Prophylaxis “Currently, healthcare practitioners use a complex flow diagram for determining the most appropriate strategies when providing VTE prophylaxis,” explains Elliott R. Haut, MD, FACS. For a study, Dr. Haut and colleagues converted the complex algorithm into a shorter clinical decision support-enabled VTE order set that was built into a computerized provider order entry system (CPOE). The converted algorithm was used at the point of care by trauma services providers at the Johns Hopkins Hospital in the analysis. For the intervention, clinicians checked off appropriate boxes on a short checklist (Table) based on patients’ VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The CPOE system integrated this information into an evidence-based algorithm to stratify patients’ VTE risk. The system then suggested the optimal decision for an appropriate VTE prophylaxis regimen. “Using the order set was mandatory for all adult trauma patients in our study,” adds Dr. Haut, whose research was published in JAMA Surgery. The study team compared compliance with guideline-appropriate VTE prophylaxis during the year prior to implementing the order set with the 3 years after implementation. Increased...

Managing Thromboembolism in Pregnancy

Thromboembolism is a leading cause of maternal morbidity and mortality in the United States. The risk of venous thromboembolism (VTE) is increased four-fold during pregnancy and another five-fold for 6 weeks following delivery. The increased VTE risk for these women is mainly attributed to pregnancy because it puts the body in an increased thrombogenic state, but physiologic factors, such as an enlarged uterus and compressed blood vessels at the time of childbirth, also play a role. Other risk factors include having a prior VTE, family history of thrombosis, smoking, high blood pressure, obesity, and operative delivery. The consequences of VTE during pregnancy can be severe and often stem from a failure in diagnosis rather than inadequate therapy. An updated practice bulletin from the American College of Obstetricians & Gynecologists (ACOG) was published in the September 2011 issue of Obstetrics & Gynecology to provide clinicians with updated information on the risk factors, diagnosis, management, and prevention of VTE. “This document places more emphasis on the acquired risk factors for VTE during pregnancy,” says Andra H. James, MD, who helped develop the bulletin. “The recommendations explain how to monitor women for thromboembolic events, address certain risk factors, and treat suspected or acute cases of VTE. The hope is that maternal deaths can be reduced if more clinicians adopt the recommendations provided in the bulletin.” New Recommendations to Manage VTE A major recommendation offered in the ACOG update is the use of compression ultrasonography of the proximal veins when signs or symptoms are suggestive of new onset DVT (Figure). Use of compression ultrasonography will indicate if treatment should be started or surveillance...

CHEST 2012: Fainting After Air Travel May Indicate Pulmonary Embolism

Fainting after recent air travel could be a sign of pulmonary embolism (PE), a potentially fatal blockage in the lungs. Syncope or fainting is an uncommon symptom of pulmonary embolism; however, new research presented at CHEST 2012, the annual meeting of the American College of Chest Physicians (ACCP), found that fainting associated with recent air travel may be a key indicator of PE diagnosis. Fainting as a precursor to PE diagnosis was also associated with a saddle embolism, a larger and more life-threatening form of PE, as well as more abnormal ECG readings. “Fainting may be an atypical symptom of PE, but fainting associate with recent air travel is a dangerous combination,” said lead study author Robert Rifenburg, MD, Resurrection Medical Center, Chicago, Illinois. Due to the proximity to Chicago’s O’Hare airport, one of the busiest airports in the United States, Resurrection Medical Center sees many sick travelers who are coming directly from the airport. “If you come to our hospital from O’Hare for evaluation of a fainting episode, and you are ultimately diagnosed with a PE as the cause of your fainting episode, the likelihood that this is a life-threatening PE is high.” To determine the connection between fainting and PE, Dr. Rifenburg and colleagues retrospectively reviewed medical records of 548 patients (mean age 68.9) presenting to the emergency department (ED) and admitted to the hospital with a new PE over a 5-year period. Data collection included demographics, airplane travel history, initial chief complaint, location and type of PE, ECG findings, and echocardiography results. Of the patients, 10% (n=55) presented to the ED with fainting as their chief...
Managing Pulmonary Embolism in the ED

Managing Pulmonary Embolism in the ED

Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), is the third leading cause of cardiovascular death among Americans and is especially fatal if these events go undiagnosed and are not treated promptly. PE is most frequently diagnosed in the ED and is associated with 14- and 30-day mortality rates of about 10% and 20%, respectively. Research has shown that a prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. Factors Associated with Delays in PE Diagnosis My colleagues and I previously reported that administra­tion of anticoagulants within 24 hours of ED arrival is as­sociated with reduced mortality. Current guidelines from the American College of Chest Physicians recommend that anticoagulation be initiated even before a confirmed diag­nosis, when the probability of PE is believed to be high. However, studies have indicated that there is potential for significant delays from the time of symptom onset to PE diagnosis in the ED. A prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. In an effort to better understand the factors associated with timing of a PE diagnosis in the ED, my colleagues and I conducted a review that was published in the January 2012 Journal of Emergency Medicine. Following univariate and multivariate analyses, we found that the following factors appeared to be associated with delays in PE diagnoses of more than 12 hours: Age older than 65. Concurrent cardiovascular disease (CVD). Morbid obesity (BMI >40 kg/m2). A history of recent immobility (eg, recent surgery) and pre­sentation to the ED with tachycardia were factors associ­ated with a relatively early diagnosis of...
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