Pleuritic chest pain - Centre for Rural Emergency Medicine

Acute Pleuritic Chest Pain
Tim Baker
8:CIG:;DG
RURAL
EMERGENCY
MEDICINE
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Learning objectives
To recognise two common myths about pleuritic chest pain
To know when to order a D-dimer, CTPA, or V/Q scan
To know when to doubt the result of a CTPA
Outline
Pleuritic pain
Myths
Approach
Cases
What is pleuritic pain like?
Pain that is exacerbated during breathing, coughing, talking or sneezing
Breath holding relieves pain
Localised, shooting or stabbing
Can be constant background pain
Is it really pleuritic?
Poorly reliable - Kappa 0.4 (0.2 - 0.4 moderate agreement)
Pain on breathing versus hard to breath or pain on movement
Deep breath or cough only partially reproduces the pain
Pleuritic pain myths
Myth one: Pleuritic chest pain
excludes acute coronary syndrome
ports the diagnosis o
e 2. Value of Specific ComponentsTable
of the 2.
Chest
Value
Pain
of History
Specificfor
Components
the Diagnosis
of the
of Acute
Chest Pain History for the Diagnos
dition to relaxing
cardial Infarction (AMI)
Myocardial Infarction (AMI)
Downloaded from www.jama.com at MONASH
Downloaded
MEDICAL
from www.jama.com
CENTRE LIBRARY,
at MONASH
on November
MEDICAL
27, 2005
CENTRE LIBR
muscle, nitroglyce
Positive Likelihood
Positiv
ation
of esophageal
m
RatioReference
(95% CI)
No.
of Patients
Ratio
Less likely, but not excluded
Pain Descriptor
Reference
Pain Descriptor
No. of Patients
ased likelihood of AMI
Increased likelihood of AMI
alleviate esophageal c
adiation to right arm or shoulder
Radiation
29
to right arm 770
or shoulder
4.7 (1.9-12)
29
770 Convention
4.7
as well.
adiation to both arms or shoulders
Radiation
14
to both arms893
or shoulders 4.1 (2.5-6.5)
14
893
4.1
that relief
of cardiac
ssociated with exertion
Associated
14
with exertion
893
2.4 (1.5-3.8)
14
2.4
than 893
5CORONARY
minutes),
wh
CHEST PAIN HISTORY IN PATIENTS
CHEST
WITH
PAIN
SUSPECTED
HISTORY ACUTE
IN PATIENTS
CORONARY
WITH SYNDROMES
SUSPECTED ACUTE
SYND
adiation to left arm
Radiation
24
to left arm 278
2.3 (1.7-3.1)
24
278
2.3
pain takes more than
ssociated with diaphoresis
Associated
24
with diaphoresis
8426
2.0 (1.9-2.2)
24
8426
2.0
9
pretest odds x likelihood ratio = post test odds side.
However, rec
48
ports the diagnosis
of angina.
ssociated
nausea
or vomiting
Associated
242.Chest
nausea
970
orthe
vomiting
1.9
(1.7-2.3)
24
970
1.9
Tablewith
2. Value
of Specific
ComponentsTable
of the
Valuewith
Pain
of Specific
History
Components
for
Diagnosis
of the
ofChest
Acute
Pain History for
the
Diagnosis
of Acute
cate
that
there
is
dition to relaxing coronaryn
ofInfarction
Acute
Myocardial
Infarction
Infarction
(AMI)
Myocardial
(AMI)
Worse Myocardial
than previous
angina
or similar Chance
Worse
29 than
previous
7734
angina or similar
1.8 (1.6-2.0)
29
7734
1.8
tween
AMI
and
relief
muscle,
nitroglycerin
cause
to previous MI
to previous MI
Positive Likelihood
Positive Likelihood
50,51
ofnitroglycerin.
esophageal
muscle
and t
Pain Descriptor
Reference
Pain Descriptor
No. of Patients
Ratio
Reference
(95% CI)
No.ation
of Patients
Ratio
(95%
CI)
escribed as pressure
Described
29
as pressure
11 504
1.3 (1.2-1.5)
29
11 504
1.3
alleviate esophageal
causes of ch
“GI
Cocktail.”
T
4.7 (1.9-12)
29
770 Conventional
4.7 (1.9-12)
as well.
teachin
0.214(0.1-0.3)
29
8822 4.1 (2.5-6.5)
0.2e
commonly
used
in
4.1 (2.5-6.5)
that893
relief
of
cardiac
pain
is
rap
Swap, 2005, JAMA,
0.3
(0.2-0.5)
29
8330
0.3
2.4 (1.5-3.8)
14
(1.5-3.8)
294(20):2623-9.
to2.4whereas
treat
dysp
than893
5ments
minutes),
eso
to left arm
Radiation
arm 1088
278
2.3 (1.7-3.1)
2.3 (1.7-3.1) 0.3
escribedRadiation
as sharp
Described
2924 to
asleft
sharp
0.324(0.2-0.5)
29 pain278
1088
tions
vary,
but
it is
takes
more
than
10 minute
Associated with diaphoresis
Associated
24
with diaphoresis
8426
2.0 (1.9-2.2)
24
8426
2.0
(1.9-2.2)
eproducible with palpation
Reproducible
29
with palpation
8822
0.3 (0.2-0.4)
29 side.9 of
8822 recent
0.3
However,
studi
viscous
lidocaine
Associated with nausea or vomiting
Associated
24
with nausea970
or vomiting
1.9 (1.7-2.3)
24
970
1.9 (1.7-2.3)
there
framammary location
Inframammary
31
location903
0.8 (0.7-0.9)
31 cate that
903 is no associat
0.8
(comp
Worse than previous angina or similar
Worse
29than previous angina
7734 or similar 1.8 (1.6-2.0)
29
7734and Donnatal
1.8 (1.6-2.0)
AMI and
chest0.8
p
to previous
MI
to previous MI
ot associated
with exertion
Not14
associated
with exertion
893
0.8 (0.6-0.9)
14 tween ticholinergics
893relief of and
a
b
50,51
nitroglycerin.
Described
pressure infarction; CI,
Described
29 interval.
as pressure
504
1.3 (1.2-1.5)
11 504
1.3 (1.2-1.5)
viations: AMI,
acute as
myocardial
Abbreviations:
confidence
AMI,
acute11
myocardial
infarction;
CI,29
confidence interval.
been
common
prac
“GI Cocktail.” The GI
coc
Decreased likelihood of AMI
Decreased likelihood of AMI
Described as pleuritic
Described
29
as pleuritic8822
0.2 (0.1-0.3)
29
8822cocktail
0.2
(0.1-0.3)
toemergency
different
commonly
used in
Described
positional
Described
29
as and
positional
8330
(0.2-0.5)
29
8330that
0.3 (0.2-0.5)
ments
to treat
dyspepsia.
Co
strated
that
it suggests0.3
a non-ACS
strated
etiit suggests
a no
cipitating
and as
Aggravating
Factors
Precipitating
Aggravating
Factors
esophageal
chest
pa
Described as sharp
Described
29
as sharp
1088
0.3
(0.2-0.5)
29
1088
0.3
(0.2-0.5)
tions2,3,14,25
vary,
but
it is the
usually
a
(20
%) 2,3,14,25 construct
(5 %)
ology.
ology.
asy-to-remember
construct
for
An
poseasy-to-remember
for
posstudy
from
1970s
Reproducible with palpation
Reproducible
29
with palpation
8822
0.3 (0.2-0.4)
29
8822
0.3 (0.2-0.4)
of viscous
lidocaine,
a liquid
e precipitating
factors
is
the
3
sible
p’s,
precipitating
Exercise.
factors
The
association
is
the
3
p’s,
between
Exercise.
The
association
recent
studies
and
ca
Inframammary location
Inframammary
31
location903
0.8 (0.7-0.9)
31
0.8 (0.7-0.9)
and 903
Donnatal (composed
of sev
Increased likelihood of AMI
Increased likelihood of AMI
eased likelihood
of AMI
Radiationof
to AMI
right arm or shoulder Decreased
Radiation
29likelihood
to right arm
or
770
shoulder
escribedRadiation
as pleuritic
Described
29
as
pleuritic
8822
to both arms or shoulders
Radiation
14 to both arms893
or shoulders
escribedAssociated
as positional
Described
2914 as
positional
8330
with exertion
Associated
with
exertion
893
1 to 4 chance x 0.2 = 1 to 20 chance
Pleuritic chest is unhelpful if
There are other findings or risk factors that suggest a cardiac cause
You are looking for unstable angina, not AMI
Pain is only partially reproducible
Myth two:
Pleuritic pain ≡ Pulmonary embolus
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89:./;%7-#7%)9+
<$.7%)9+
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Poor sensitivity
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"
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1%&"0.&F;&7(="20"+&:&.*)"(2<<27"+,@7+"*7E"+=<912<+"G#H5""
"
Only 50 % of PE
patients have pain
Demographic - Sign - Symptom
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*7E"+=<912<+"E2&+"721"&J();E&"1%&"E,*@72+,+I""KEE,1,27*))=B"27&".&(&71"+1;E="&J*<,7&E"1%&"
(),7,(*)"0&*1;.&+"20"9*1,&71+"L,1%"*"E&)*=&E"&<&.@&7(="E&9*.1<&71"E,*@72+,+"20"34"*7E"02;7E
1%2+&"9*1,&71+"1&7E&E"12">&"2)E&.B"%*E"*"%,@%&."0.&F;&7(="20"<&71*)"+1*1;+"(%*7@&+B"*7E"*"%,@
,7(,E&7(&"20"*E:&.+&"%2+9,1*)"2;1(2<&+I"M7)="DN"OP",7"AQR"20"9*1,&71+",7"1%&"E&)*=&E"E,*@72
Poor specificity
Chest pain - 1 % has a pulmonary embolus
Pleuritic chest pain - 5 % has a pulmonary embolus
Frequency doubles each with decade of life
We often worry in the young and fit, but should mainly
worry in the old and unwell
Approach
Pleuritic chest pain
History, examination, O2 saturation , ECG
Investigate
and treat
Obvious cause
Chest x-ray
Infiltrate
Effusion
Pneumonia,
malignancy,
pulmonary embolus
Transudate,
pus,
tumour,
blood
Clear
Separation
Cardiomegaly
Pneumothorax
Chronic
pericarditis
Could this be
acute coronary
syndrome?
ACS work up
Could this be
a pulmonary
embolus?
PE work up
Undifferentiated chest pain
Cases
Case one - Mrs Gladys Notme
A 71-year-old woman presents with one day pleuritic left posterior chest pain
and shortnesss of breath. She was in hospital three weeks ago with an
exacerbation of COPD. She has diabetes, hypertension, and had a DVT 10
years ago. Her temperature is 37.2°C, and her pulse is 105 beats per minute.
Physical examination discloses occasional wheeze, but is otherwise
unremarkable. An electrocardiogram and chest radiograph are both normal.
Would a D-dimer be useful?
How useful is a
D-dimer?
False positive = 48 %
Positive likelihood ratio = 2
10 %
Negative likelihood ratio = 0.07
60 %
Low risk
High risk
10 % chance of PE
LR- 0.07
1 % chance of PE
Low clinical risk
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Chance of PE
(after history and exam)
10 %
Negative
D-Dimer
LR- 0.07
LR+ 2.0
Positive
D-Dimer
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Chance of PE 1 %
Chance of PE 20 %
High clinical risk
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Chance of PE
(after history and exam)
60 %
Negative
D-Dimer
LR- 0.07
LR+ 2.0
Positive
D-Dimer
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Chance of PE 10 %
Chance of PE 75 %
When is a D-dimer useful?
Strategies for Ruling Out PE in the ED
%&'()&"*"+,-*,&./"0*+&1"2)"/23-"4*,(&),"42435*,(2)6"*7*(5*05&"-&+23-8&+6"*)1"4-*8,(8&"+&,,().9""
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"
!"#$%&'()*+(
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=%&%##04D(
sponds to a pretest probability for PE. With either system, low-risk patients (40% to 49% of total patients)
had less than a 10% probability of PE, and high-risk
patients (6% to 7% of total patients) had greater than
What is the clinical risk?
Table 1.
Wells et al41 criteria for assessment of pretest probability for
PE.
Well’s criteria
Criteria
Points
Suspected DVT
An alternative diagnosis is less likely than PE
Heart rate >100 beats/min
Immobilization or surgery in the previous 4 wk
Previous DVT/PE
Hemoptysis
Malignancy (on treatment, treated in the past 6 mo or palliative)
Score Range
<2 points
2–6 points
>6 points
3.0
3.0
1.5
1.5
1.5
1.0
1.0
Mean Probability
of PE, %
% With
This Score
Interpretation
of Risk
3.6
20.5
66.7
40
53
7
Low
Moderate
High
Reprinted with permission from Wells PS, Anderson DR, Rodger M, et al. Derivation of
a simple clinical model to categorize patient’s probability of pulmonary embolism:
increasing the models utility with the SimpliRED D-dimer. Thromb Haemost.
2000;83:416-420.
Table 2.
Wicki et al42 criteria
PE.
Criteria
Age 60–79, y
Age >79, y
Prior DVT/PE
Recent surgery
Heart rate >100 beats/min
PaCO2, mm Hg
<36
36–39
PaO2, mm Hg
<49
49–60
>60–71
>71–82
Chest x-ray
Plate-like atelectasis
Elevation of hemidiaphragm
Score Range
Me
0–4
5–8
9–12
Reprinted with permission from
probability of pulmonary emboli
Med. 2001;161:92-97. Copyrighte
Exclusion criteria. Pregnant patients and asymptomatic
patients.
65% probability of PE. Intermediate-risk patients comprised approximately half of the patients with a probability of PE in the 20% to 40% range. Sanson et al44 performed a multicenter trial comparing subjective
physician judgement of pretest probability for PE to the
extended Wells et al39 model and the simplified Wells et
al40,41 model. In this study, the rates of PE in the lowrisk groups were 19% for subjective physician judgement, 28% for the extended Wells et al model, and 28%
in the simplified Wells et al44 model. The 3 methods
yielded comparative predictive values in patients with
intermediate and high risk for PE. These findings
emphasize the need for ongoing prospective studies to
validate and improve structured models for predicting
risk of PE.45 The Kline et al43 scoring system was developed to identify patients who were safe for use of D-dimer
testing for exclusion of PE (Figure). In this study, 934
patients with suspected PE were prospectively inter-
Case one - Mrs Gladys Notme
CRITICAL ISSUES IN PULMONARY
EMBOLISM
Estimation of pretest probability of the disease is imperative for proper application of results of diagnostic testing. The pretest probability of PE can be estimated by
using explicit criteria that are available in virtually
every ED. Multiple methods have been examined, but
the 3 methods that appear to be most applicable to ED
patients are the Wells et al39-41 criteria derived from a
thromboembolism referral center in Canada, the Wicki
et al42 criteria derived from a single hospital in Switzerland, and the Kline et al43 criteria derived from 7 urban
EDs in the United States. The Wells et al and Wicki et al
scoring system assign a number to certain specific findings in patients with suspected PE (Table 1 and 2). The
numbers are added up to generate a score, which corresponds to a pretest probability for PE. With either system, low-risk patients (40% to 49% of total patients)
had less than a 10% probability of PE, and high-risk
patients (6% to 7% of total patients) had greater than
A 71-year-old woman presents with one day pleuritic left posterior chest pain,
and shortnesss of breath. She was in hospital three weeks ago (1.5) with an
exacerbation of COPD. She has diabetes, hypertension, and had a DVT (1.5)
10 years ago. Her temperature is 37.2°C, and her pulse is 105 beats per
minute (1.5). Physical examination discloses occasional wheeze, but is
otherwise unremarkable. An electrocardiogram and chest radiograph are both
normal (3).
Table 2.
Wicki et al42 criteria for assessment of pretest probability for
PE.
Criteria
Table 1.
Wells et al41 criteria for assessment of pretest probability for
PE.
Criteria
Points
Suspected DVT
An alternative diagnosis is less likely than PE
Heart rate >100 beats/min
Immobilization or surgery in the previous 4 wk
Previous DVT/PE
Hemoptysis
Malignancy (on treatment, treated in the past 6 mo or palliative)
Score Range
Mean Probability
of PE, %
% With
This Score
3.0
3.0
1.5
1.5
1.5
1.0
1.0
Interpretation
of Risk
Points
Age 60–79, y
Age >79, y
Prior DVT/PE
Recent surgery
Heart rate >100 beats/min
PaCO2, mm Hg
<36
36–39
PaO2, mm Hg
<49
49–60
>60–71
>71–82
Chest x-ray
Plate-like atelectasis
Elevation of hemidiaphragm
Score Range
Mean Probability
of PE, %
1
2
2
3
1
Score = 7.5
High risk
2
1
4
3
2
1
1
1
% With
This Score
Interpretation
of Risk
High risk imaging
D9'+"72E((
FG(456("7,-(HI("%(!JF(3$7"8%&9:-(
5%$&'(
L+8:()%"*&*+,+'-"
45(678+"8%&9:-("%(45(
CT
pulmonary angiography
678+"8%&9:-(;45(<$7"8%&9:-(
456(C$8&'+3$(=C)<(MB@A((
CTPA negative (NPV 60 %)
456;45<(C$8&'+3$(=C)<(K?@A(
✰
D9'+"72E((
Repeat
CTPA
if poor quality, add CT
J$9$&'(456;45<(+G(9""%(NO&,+'-.(&##(HI("%(!JF(
venography,ultrasound,
V/Q, MRI, or ultrasound
3$7"8%&9:-(+G(456("7,-.(<;P.(/I6.(I$%+&,(HI(
456()"2+'+3$((=))<(>M@A((
CTPA positive (PPV 96 %)
456;45<()"2+'+3$(=))<(>M@A(
5%$&'(
Case two - Mr Justin Case
A 66-year-old man presents with two days of dry cough and pleuritic right
sided chest pain, one week after a flight from Peru. He is otherwise well, with
no relevant past illness. His temperature is 37.2°C, and his pulse is 80 beats
per minute. Physical examination, electrocardiogram and chest radiograph
are all normal.
What is your approach?
et al criteria derived from a single hospital in Switzerland, and the Kline et al43 criteria derived from 7 urban
EDs in the United States. The Wells et al and Wicki et al
scoring system assign a number to certain specific findings in patients with suspected PE (Table 1 and 2). The
numbers are added up to generate a score, which corresponds to a pretest probability for PE. With either system, low-risk patients (40% to 49% of total patients)
had less than a 10% probability of PE, and high-risk
patients (6% to 7% of total patients) had greater than
Case two - Mr Justin Case
risk of PE. T
oped to identi
testing for exc
patients with
Table 2.
Wicki et al42
PE.
Criteria
Table 1.
A 66-year-old man presents with two
days of dry cough and pleuritic right
sided chest pain, one week after a
flight from Mexico (1.5). He is
otherwise well, with no relevant past
illness. His temperature is 37.2°C,
and his pulse is 80 beats per minute.
Physical examination,
electrocardiogram and chest
radiograph are all normal.
Wells et al41 criteria for assessment of pretest probability for
PE.
Criteria
Points
Suspected DVT
An alternative diagnosis is less likely than PE
Heart rate >100 beats/min
Immobilization or surgery in the previous 4 wk
Previous DVT/PE
Hemoptysis
Malignancy (on treatment, treated in the past 6 mo or palliative)
Score Range
<2 points
2–6 points
>6 points
3.0
3.0
1.5
1.5
1.5
1.0
1.0
Mean Probability
of PE, %
% With
This Score
Interpretation
of Risk
3.6
20.5
66.7
40
53
7
Low
Moderate
High
Reprinted with permission from Wells PS, Anderson DR, Rodger M, et al. Derivation of
a simple clinical model to categorize patient’s probability of pulmonary embolism:
increasing the models utility with the SimpliRED D-dimer. Thromb Haemost.
2000;83:416-420.
2 6 0
Score = 1.5
Low risk
Age 60–79, y
Age >79, y
Prior DVT/PE
Recent surgery
Heart rate >100 be
PaCO2, mm Hg
<36
36–39
PaO2, mm Hg
<49
49–60
>60–71
>71–82
Chest x-ray
Plate-like atelecta
Elevation of hemid
Score Range
0–4
5–8
9–12
Reprinted with permi
probability of pulmon
Med. 2001;161:92-97.
ANN
Rule out pulmonary embolism
Strategies for Ruling Out PE in the ED
%&'()&"*"+,-*,&./"0*+&1"2)"/23-"4*,(&),"42435*,(2)6"*7*(5*05&"-&+23-8&+6"*)1"4-*8,(8&"+&,,().9""
:++&++",;&"4*,(&),<+")&&1"'2-",&+,().6"*)1"4-&!,&+,"5(=&5(;221"2'">?"3+().",;&"85()(8*5".3(1&+"
1&+8-(0&1"*027&"@>?AB6"C&55+6"D&)&7*6"2-"/23-"E2+,"5(=&5/"1(*.)2+(+F9"G;&)"3,(5(H&"%!1(E&-+"()"
52I"-(+="4*,(&),+",2"&J8531&"7&)23+",;-2E02&E025(+E9"K,&()"*)1",;&">LM>?%"LL"()7&+,(.*,2-+"
*,,&E4,&1",2"-&82)8(5&",;&"'()1().+"()",;&(-"()7&+,(.*,(2)"*)1",;2+&"2'",;&"B;-(+,24;&-"D-234"*)1"
4-&+&),&1",;&"'2552I()."-&82EE&)1&1"1(*.)2+,(8"4*,;I*/+9N$OP""
"
!"#$%&'()*+(
,-./.&0-(123(24(526%40'%(
:;:.<%4(=%80'.>%(
)*(?24@;A$(
,2<$-%'%(
,-./.&0-(7.89(
:;:.<%4()2#.'.>%(
B"4'9%4(C%#'./8(
=%&%##04D(
123()42E0E.-.'DF((
:;:.<%4()2#.'.>%
B"4'9%4(C%#'./8(
=%&%##04D(
:;:.<%4(=%80'.>%(
:;:.<%4()2#.'.>%(
Low risk imaging
)*(?24@;A$(
,2<$-%'%(
B"4'9%4(C%#'./8(
=%&%##04D(
B"4'9%4(C%#'./8(
=%&%##04D(
123()42E0E.-.'DF((
:;:.<%4()2#.'.>%
,C(G/8.2840$9D(24((
CT pulmonaryH,C(I%/2840$9D(
angiography
,C(G/8.2840$9D
,CG(=%80'.>%((J=)I(PQMN((
CTPA negative (NPV 96 %)
,CGH,CI(=%80'.>%(J=)I(POMN
)*(?24@;A$(
,2<$-%'%(
✰
,CG()2#.'.>%((J))I(KLMN((
CTPA
positive (PPV 58 %)
,CGH,CI()2#.'.>%(J))I(KOMN
!%8<%/'0-(J))I(QOMN(
!"E#%8<%'0-(J))I(RKMN
50./(24(12E04()*(
J))I(POMN
S$'.2/#T((
Repeat CTPA if poor quality, add CT
U%$%0'(,CGH,CI(.V($224(W"0-.'DF(066(A!(24(5UX(
venography,ultrasound,
V/Q, MRI, or ultrasound
>%/2840$9D(.V(,CG(2/-DF(IHYF(:!GF(!%4.0-(A!(
C4%0'(
Intermediate risk imaging
!"#$%&'$()%"*&*+,+'-.((
/0/+1$%()"2+'+3$"
45(678+"8%&9:-("%((
CT pulmonary angiography
45(678+"8%&9:-(;45(<$7"8%&9:-((
456(C$8&'+3$(=C)<(K>@A((
456;45<(C$8&'+3$(=C)<(>?@A(
CTPA negative (NPV 89 %)
456()"2+'+3$((=))<(>?@A((
456;45<()"2+'+3$(=))<(>B@A(
CTPA positive (PPV 92 %)
C"(5%$&'1$7'(
✰
D9'+"72E((
Add CT venography,ultrasound,
V/Q,
FG(456("7,-(HI("%(!JF(3$7"8%&9:-(
MRI, or ultrasound
5%$&'(
Case three - Mr Knut Tuscick
A 34-year-old man woke today with pleuritic right sided chest pain, partially
relieved with neurofen. He has no associated symptoms. He is otherwise well,
but not very fit. The tree planting he attended yesterday was his first really
hard physical exertion for months. He has no relevant past illness and takes
no medications. His temperature is 36°C, and his pulse is 80 beats per
minute. Physical examination, electrocardiogram and chest radiograph are all
normal.
What is your approach?
“No risk” of pulmonary embolism
Pulmonary Embolism
Rule-out Criteria (PERC)
Likelihood ratio of 0.17
No fatal PE in 1500
patients
PERC
(Workup if any one abnormal)
Age < 50
Pulse <100
Oxygen saturation > 94%
No unilateral leg swelling
No haemoptysis
No recent surgery or trauma
No prior PE or DVT
No hormone use
Case four - Ms Sophia Choice
A 28-year-old woman who is 32 weeks pregnant presents with three days of
severe pleuritic left chest pain and shortnesss of breath. The pregnancy has
been unremarkable, and she has no relevant past illnesses. Her temperature
is 37.2°C, and her pulse is 105 beats per minute. An electrocardiogram and
chest radiograph are both normal. D-dimer is positive and lower limb doppler
is negative.
What is your approach
V/Q or CTPA?
V / Q scan
CTPA
1 mSv radiation
14 mSv radiation to mother
99mTc albumin 0.9 mSv
Only 1 % scatters to embryo
133Xe <0.01 mSv
0.14 mSv to foetus (T3)
Radiation reaches foetus in
blood and from bladder
Indeterminate scans common
(but less so in the young)
Risks of radiation
For foetus
For mother
Increased risk of childhood cancer
Increased risk of breast cancer
V/Q by 1 in 280,000
V/Q - practically no increase
CTPA by 1 in 1,000,000
CTPA 1 in 2000
(100 mSv needed for CNS
malformations)
From a background risk of
10 in 2000 to 11 in 2000
Conclusion
Summary
Pleuritic chest pain excludes acute coronary syndrome
Pleuritic chest pain ≡ pulmonary embolus
D-Dimer should be used in low and intermediate risk patients
(not “no risk” or high risk patients)
negative excludes PE
positive requires further testing
Consider further testing when CTPA disagrees with clinical picture
Inform pregnant patients of radiation risks
Questions?
References
Swap, CJ.J. Nagurney, J.T. 2005, Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes, JAMA.
Nov 23;294(20):2623-9.
Bowman, s. h. (2007, October 8). The ever elusive pulmonary embolism: A logical approach. ACEP scientific assembly. http://www.acep.org/WorkArea/
DownloadAsset.aspx?id=46350
American College of Emergency Physicians Clinical Policies Committee & Clinical Policies Committee Subcommittee on Suspected Pulmonary Embolism,
2003, Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Annals of
emergency medicine, 41(2), pp. 257-70.
Tapson, V.F., 2008, Acute pulmonary embolism, The New England journal of medicine, 358(10), pp. 1037-52.
Kline, J. A., Mitchell, A. M., Kabrhel, C., Richman, P. B., & Courtney, D. M. (2004). Clinical criteria to prevent unnecessary diagnostic testing in emergency
department patients with suspected pulmonary embolism. J Thromb Haemost, 2(8), 1247-55.
Marik, P.E. & Plante, L.A., 2008, Venous thromboembolic disease and pregnancy, The New England journal of medicine, 359(19), pp. 2025-33.