There are five causes of chest pain that I teach in my Demystifying Emergency Medicine system.
- P=Pericarditis
- A=AMI
- P=PE
- P=Pneumothorax
- A=Aneurysm
I also teach five causes of pulmonary symptoms in the Demystifying Emergency Medicine system:
- H=Heart
- O=Obstruction
- R=Reactive
- I=Infection
- D=Death (from PE or pneumothorax)
PE is on both mnemonics. What’s the problem? It’s not it the treatment. The treatment is easy. We anticoagulant
them. The problem is in the diagnosis. But, why? Well, because it masquerades like so many other problems.
What symptoms do patients present with?
- SOB~80%
- CP~65%
- Cough~35%
- Leg Swelling~25%
- Hemoptysis ~20%
- Sweating ~30%
What signs will a PE have?
- Tachypnea ~55%
- Tachycardia~50%
- Abnormal Lung Sounds~50%
- Leg Swelling~25%
- Circulatory Collapse~25%
I am with you. I don’t like a lot of numbers either. But, look at them. 80% have SOB, yet, 20% don’t. 65% have CP, yet, 35% don’t. 55% have tachycardia, yet, 45% have a normal heart rate. This makes PE a tricky diagnosis.
I have diagnosed about 100 PEs in my 17 years in medicine. I have not been burned… not yet at least.
I recommend you use the mnemonics PAPPA and HORID with every CP and SOB. EVERY ONE. This keeps PE on your radar. Make sure your documentation reflects that you thought of PE with specific medical decision-making and pertinent negative.
I have found the risk factors of Virchow’s Triad have saved my butt a number of times.
I am not a big fan of the Well’s Criteria. I use Well’s from time to time, but if you do not have about 10 PEs under your belt, I feel Well’s is diluted. I like the PERC rules. It’s easy to remember and apply.
What has worked best for you?
Image Courtesy of FreeDigitalPhotos.net/Stuart Miles
PERC = Pulmonary Embolism Rule-out Criteria
Pulmonary embolism can be ruled out clinically if none of the 8 PERC criteria are present in a patient with a low pretest probability of PE (e.g. Wells PE CPG score of <3) that is consistent with the ‘gestalt‘ of an experienced physician:
age < 50 years
pulse or= 95%
no hemoptysis
no estrogen use
no surgery/trauma requiring hospitalization within 4 weeks
no prior venous thromboembolism (VTE)
no unilateral leg swelling
Can’t remember all of this?
Try this mnemonic suggested by the guys at Keeping Up in Emergency Medicine to remember which patients the PERC rule can’t be used on:
HAD CLOTS
H ormone, A ge >50, D VT/PE history, C oughing blood, L eg swelling, O 2 >95%,
T achycardia 100+, S urgery/trauma <28 d