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Managing Venous Thromboembolism in the Emergency Department November 9, 2017

Managing Venous Thromboembolism in the Emergency Department November 9, 2017. Jeffrey A Kline, MD Department of Emergency Medicine Indiana University School of Medicine @ klinelab. Disclosures. JAK Research funding: NIH, Ikaria Consultant: Diagnostica Stago Advisory Board: Janssen

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Managing Venous Thromboembolism in the Emergency Department November 9, 2017

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  1. Managing Venous Thromboembolism in the Emergency DepartmentNovember 9, 2017 Jeffrey A Kline, MD Department of Emergency Medicine Indiana University School of Medicine @klinelab

  2. Disclosures JAK Research funding: NIH, Ikaria Consultant: DiagnosticaStago Advisory Board: Janssen Stock: CP Diagnostics

  3. Session overview • Risk factors for PE in the ED • Ruling out PE without imaging • Risk stratification to allow home treatment

  4. Risk Factors for PE • Epidemiological studies vs. symptomatic ED patients Years OUTCOME 6-8 weeks PE or not Kline JA , Kabrhel C. J Emerg Med. 2015, 48:771-80

  5. Doubts and Certainties Certain increased risk IN ED Not a risk or uncertain IN ED Travel Smoking Obesity Family history Pregnancy Lines, infection, nursing home Heart failure and a-fib • Recent surgery (GETA or epidural) • Prior VTE • Estrogen use • Non-O blood type • Extremity immobility • Post-partum (<5 days) • Active cancer Kline JA , Kabrhel C. J Emerg Med. 2015, 48:771-80

  6. Pregnancy Relative risk of pregnancy: 0.60 (95% CI = 0.41 to 0.87). Third trimester: 0.85 (0.40 to 1.77). Pregnancy vs. all patients < 45 years: 0.56 (0.34 to 0.93). Kline JA et al. Acad Emerg Med. 2014; 21:949-59

  7. Immobility RR 1.1 (0.7-1.6) RR 2.3 (1.7-3.4) RR 2.1 (1.4-3.0) RR 2.6 (1.8-3.8) RR 2.0 (1-3.9) Beam DM et al Ann Emerg Med, 2009, 54:147-52

  8. History of present illness FeatureSignificant predictor*? • Unexplained dyspnea YES • Pleuritic chest pain YES • Substernal chest pain NO • Syncope PROBABLY NOT • Hemoptysis YES • Dizziness PREDICTS NOTHING *Learning objective Courtney DM et al. Ann Emerg Med. 2010, 55:307-315

  9. Comparison of risks Sudden onset Pleuritic CP Substern. CP Estrogen Inactive CA Obesity Smoking Dyspnea Family Hx VTE Courtney DM et al. Ann Emerg Med. 2010, 55:307-315

  10. Physical findings FindingSignificant predictor*? • Heart rate >100 YES • RR >22 INCONSISTENT • SaO2<95% YES • sBP <100 ? • T>101 NO • Rigid affect MAYBE *Learning objective Stein PD, et al. Am J Med 2007;120:871-879.

  11. Vital sign trends? Kline JA et al Acad Emerg Med. 2012,19:11-7

  12. The median of all FACS values from disease+ patients 3.4 (1st-3rd quartiles 1-6), was significantly less than the median of 7 (3-14) from disease- patients (P=0.019) Kline JA, et al. Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting. Emerg Med J 2014;32:3-8 Sick patients have blunted affect

  13. N=208 patients at Eskenazi and Methodist • Pretest estimate of smile, gestalt and Wells→ then Noldus computerized device • N=106 physicians, 50% staff/resident • RESULTS: • Smile+ MORE common in PE+ (P=0.023, χ2) • Smile+ faked out docs on alternative diagnosis ? Kline JA, et a. Emerg Med J. 2016 . PMID: 27485261

  14. Physical findings FindingSignificant predictor*? • Wheezing YES (-) • Unilat leg swelling YES • Chest wall tender ? *Learning objective

  15. Bedside exclusion • Criteria to exclude PE from differential diagnosis: No shortness of breath present in history or review of systems, including no dyspnea with exertion, no chest pain and all vital signs normal at all times. • Others, use the PERC rule

  16. Probability X: Test threshold Pauker and Kassirer described in 1987 Point estimate of PTP Point of equipose where: false negative risk = false positive risk Test threshold for PE = 1-2% Zehtabchi S, Kline JA. The art and science of probabilistic decision-making in emergency medicine. Acad Emerg Med 17:521-3, 2010

  17. The PERC rule Gestalt low suspicion and: • Age < 50 • Heart rate < 100 • No hemoptysis • No estrogen use • No recent surgery • No prior PE or DVT • No unilateral leg swelling • Room air pulse oximetry ≥ 95% Kline JA et al. J Thromb Haemost 2004, 2:1247-55

  18. Single most important thing I have to say Do not try to memorize decision rules. You have better things to do. Look them up

  19. Wells <5 Known Uses gestalt SR Geneva <5 No gestalt Four ways to use a D-dimer Charlotte Rule (-) Binary No gestalt Five parts Gestalt <40% Real world Accurate Thromb Res 2017, In Press PMID: 28683951

  20. Gestalt=Wells=Geneva Sensitivity (83%) and specificity (52%) at a prevalence of PE of 15%; similar to Wells, Geneva and Revised Geneva

  21. Adjusting the D-dimer • If standard cutoff is 500 ng/mL, age*10 ng/mL yields approximately the same LR(-) as standard cutoff and an acceptably low false negative rate • From Kaiser: N= 31,094 patients with D-dimer for suspected PE, the false negative rate was 0.06% (95% CI: 0.03-0.11%) at standard cutoff and 0.18% (0.1-0.25%) using age-adjusted cutoff • (Sharp AL et al. Ann Emerg Med. 2016, 67:249-57)

  22. Non-pregnant PE exclusion algorithm Thromb Res 2017, In Press PMID: 28683951

  23. Issues with diagnosis • CTPA quality • Not all PEs created equal • Beware low quality scan • Subsegmental PE • If no DVT, it is reasonable and prudent to offer the otherwise low risk patient the option of no treatment

  24. Treatment • Who can go home? • Hestia or PESI negative and low bleeding risk • Easiest done with apixaban or rivaroxaban • Admit for anticoagulation • Admit for catheter directed lysis • Bolus lysis • ECMO/surgery

  25. Treatment • Who can go home? • Hestia or sPESI negative* and low bleeding risk • Easiest done with apixaban or rivaroxaban • Admit for anticoagulation • Admit for catheter directed lysis • Bolus lysis • ECMO/surgery *Learning objective

  26. https://twitter.com/klinelab/status/693946328100028417 Outpatient VTE for dummies: a step-by-step on how to set up a protocol to treat DVT and PE in the ED with NOACs. Beam D, et al, Acad Emerg Med. 2015 Jul;22(7):788-95. DiRenzo BM, et al,. Acad Emerg Med PMID: 28921763, 2017 Sep 16.

  27. Simplified PESI (sPESI) • 0, low risk. 1 or more, high risk. • Age > 80 • History of cancer • History of heart failure or chronic lung disease • Pulse > 110 • SBP < 100 • O2 sat < 90% Arch Intern Med. 2010, 170(15):1383-9

  28. Hestia Criteria Identifies low-risk PE if • SBP > 100 • No thrombolysis needed • No active bleeding • O2 required to maintain sats >90% • Not already anticoagulated • Severe pain requiring intravenous narcotics >24h • Other medical or social reasons to admit • Creatinine clearance >30mL/min • Not pregnant, severe liver disease or HIT Zondag et al, 2011

  29. Hestia Criteria-Modified Identifies low-risk PE if • SBP > 100 • No thrombolysis needed • No active bleeding • SaO2 >94% • Not already anticoagulated • No more than two doses of IV narcotics • Other medical or social reasons to admit • Creatinine clearance >30mL/min • Not pregnant, severe liver disease or HIT AcadEmergMed. 2015, 22:788-95 Patient Prefer Adherence. 2016, 10:561-9

  30. Do I Need Biomarkers? • Troponin positive, Hestia negative? • Observe 23 hours • BNP? • No difference in outcomes with BNP+Hestia over Hestia alone den Exter PL, et al . Am J Respir Crit Care Med. 2016 PMID: 27030891 • Jimenez et al suggest combination of sPESI + negative BNP slight improvement over sPESI. Jimenez D, et al, AJRCCM, 2014189(6):718-726.

  31. Cancer Patients • Prediction Of Mortality in Pulmonary Embolism with Cancer (POMPE-C) Thromb Res. 2012 129(5):e194-9 • Den Exter Criteria • <2 points low-risk • 30 day mortality 4.4% • 18-22% of cancer patients fit in this category Chest 2013;143:138-45.

  32. POMPE-C • Highest Respiration Rate • Oxygen Saturation • Heart Rate • Any Altered Mental Status • Respiratory Distress • DNR status • Unilateral Leg Swelling https://www.mdcalc.com/pompe-c-tool-pulmonary-embolism-mortality

  33. Rule failures • Pulmonary infarction (they bounce back for pain) • Pulmonary hypertension on ECG

  34. Rule failures • Pulmonary infarction (they bounce back for pain) • Pulmonary hypertension on ECG • Daniel score (Shopp JD, et al. AcadEmerg Med 2015; 22:1127-1137)

  35. Physician intuition of sick • Delirium (altered mental status) • Inattentiveness and distraction • Think of six emotions (happy, sad, surprise, fear, disgust, anger) • Facial affect that conveys the emotion of fear and disgust that you interpret as panic • But they can fluctuate

  36. Q. Was there any change in his condition during the time that you were there? A. Off and on. I mean, like I said, the breathing would get heavier and deeper and, you know, he'd turn one side to one side. You could see him getting pale and sweating and -- you know, and then it would tone back down, you know, and – Q. Tell me what you mean by "tone back down.“ A. I mean it is like he would go back to a non-panic state and his breathing would settle… Q. Did you talk to him any further about how he was doing, how he was feeling? A. Sure, several times. Q. Tell me what you recall being said in that regard. A. He just referred to--you know, he just referred to not--something's definitely wrong, you know, I mean, he just--breathing was off, he was dizzy, you know, he would get pale for a while and then you'd see a little color come back and see a little panic in his face and-–it was just discomfort.

  37. Emergency department anticoagulation for deep vein thrombosis or pulmonary embolism.

  38. Indiana protocol Requires: -Hestia or judgment+sPESI -Complete Blood Count (*baseline hemoglobin and platelet count) -Basic metabolic package (*creatinine clearance) -Access to anticoagulant AcadEmergMed. 2015, 22:788-95 Patient Prefer Adherence. 2016, 10:561-9 AcadEmerg Med. 2017, PMID 28921763

  39. Outcomes so far • Indiana (Four hospitals) + Dallas-Ft. Worth area (Seven hospitals ): • Approximately 700 VTE patients • 150 with PE • Within 30 days: 3 recurrent DVTs (no PEs), 3 hemorrhages requiring hospitalization (all menorrhagia) • 9 patients self-discontinued within 30 days; 5 because of television ads Data to be presented at AHA, 2017

  40. Summary • Unexplained dyspnea, pleuritic chest pain, a heart rate >100, a pulse ox <95% increase risk • Prior surgery, prior VTE and estrogen increase risk • Choose wisely--use the PERC rule and D-dimer to rule out PE • Age adjusted D-dimer is ready to use • Outpatient treatment for low risk VTE is within the bounds of standard care practice

  41. Thank you to the National Blood Clot Alliance for hosting today’s webinar. Questions about this webinar series? Please contact Cynthia Sayers at CSayers@cdc.gov. CDC Webinar Archive: www.cdc.gov.ncbddd/blooddisorders/webinar.html

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