Pulmonary Embolism Risk Stratification and ACEP Clinical Policy

iTunes or Listen Here

We cover the American College of Emergency Physicians clinical policy on Acute Venous Thromboembolic Disease (i.e. PE) [1]

Risk Stratification in Pulmonary Embolism

 In the United States, the workup rate for PE is astonishingly high, with 1-2% of all ED patients receiving a CTPA for PE and a low yield (~5-10% of CTPAs are positive for PE). Thus, major medical societies such as ACEP and the American College of Physicians recommend the use of risk stratification tools [1,2]. For some reason, approximately 25% of patients who are low risk AND PERC negative still receive d-dimer or imaging for PE, despite the risk of PE being exceptionally low. To be clear, use of clinical decision tools are not mandatory and do not necessarily perform better than clinical gestalt [9]. These tools may serve as a “reality check” for some, reminding them that patients may be at lower risk of PE than they think

Rosh Review Emergency Board Review Questions

References:

  1. Acute Venous Thromboembolic Disease. ACEP Clinical Policy. 2018
  2. Raja AS et al. Evaluation of patients with suspected acute pulmonary embolism: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701–11.
  3. Bariteau A, Stewart LK, Emmett TW, Kline JA. Systematic Review and Meta-analysis of Outcomes of Patients With Subsegmental Pulmonary Embolism With and Without Anticoagulation Treatment. Acad Emerg Med. 2018 (in Press)
  4. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost JTH [Internet]. 2004;2(8):1247–55.
  5. Buchanan I, Teeples T, Carlson M, Steenblik J, Bledsoe J, Madsen T. Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative. Acad Emerg Med. 2017;24(11):1369–76.
  6. Courtney DM, Miller C, Smithline H, Klekowski N, Hogg M, Kline JA. Prospective multicenter assessment of interobserver agreement for radiologist interpretation of multidetector computerized tomographic angiography for pulmonary embolism. J Thromb Haemost. 2010;8(3):533–9.
  7. Wells PS, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83:416-20. [PMID: 10744147]
  8. Gibson NS et al; Christopher study investigators. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008;99:229-34. [PMID: 18217159]
  9. Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, et al. Comparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism. Ann Emerg Med [Internet]. 2013 Aug;62(2):117–124.e2. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0196064412017180

Emergency Care of Lactating Patients

iTunes or Listen Here

Emergency providers receive training to care for pregnant patients but little training to care for breastfeeding patients. Many myths persist, particularly urging patients to “pump and dump” (pump and discard milk instead of feeding the baby) after medications or illness that are, in fact, completely safe to continue breastfeeding through. We review popular medications used in the emergency department (ED) as well as other pearls regarding the ED care of lactating patients (references for drugs come from LactMed, other references are listed at bottom of page).

Medications During Breastfeeding

We often obsess over medications that are safe in pregnancy but may not have much of an idea of what medications are ok in patients who are breastfeeding. Rare medications are unsafe in breastfeeding (chemotherapy, radioactive isotopes) but most that we prescribe in the emergency department are fine (including anesthesia/procedural sedation meds – see this Anesthesia graphic). Please review medications prior to prescribing to ensure that they are safe for the infant and will have no deleterious effects on lactation. For example, pseudoephedrine, a seemingly benign medication, can dry up a patient’s milk supply.

LactMed is a searchable database provided by the National Institutes of Health that summarizes the safety of medications in breastfeeding and the effects of medications on lactation. There is also a free LactMed app. Providers and patients can also call InfantRisk( 806) 352-2519  regarding specific medications (Mon-Fri 9am-6pm CST)

**Note: Some sources cite different safety profiles so we have tried to synthesize this information but depending on the patient and the source, the risk profile may be a bit different.

Medical illnesses specific to the lactating patient

General support for the lactating patient

Thanks to the physicians and lactation experts of Dr. Milk (@DoctorDrMilk) for providing peer review.

Rosh Review Emergency Board Review Questions

A 36-year-old woman presents to the office for a painful right breast for the past two days. She is one month postpartum. The patient reports swelling and redness of the right breast in addition to pain. She is febrile to 101.2°F. On physical examination, the lower lateral quadrant of the right breast is erythematous, firm, warm, and markedly tender to palpation. Enlarged right axillary lymph nodes are noted on exam. In addition to warm compresses, which of the following would be the most appropriate course of treatment?

A. Cease breastfeeding from the affected breast

B. Incision and drainage

C. Initiation of dicloxacillin 500 mg four times daily

D. Initiation of trimethoprim-sulfamethoxazole 800 mg-160 mg two times daily

Answer

C. Initiation of dicloxacillin 500 mg four times daily is the treatment of choice for postpartum women with lactational mastitis who do not have a penicillin allergy. Mastitis is an infection of the breast commonly seen in breastfeeding women from milk duct blockage, prolonged breast engorgement, and nipple trauma. The most common bacterial pathogen implicated in mastitis is Staphylococcus aureus. Patients most commonly complain of a swollen, painful, red breast. Diagnosis is a clinical one, but a breast milk culture can be performed in severe infections or infections refractory to initial treatment. For worsening symptoms or infection that is not responsive to usual treatment, an ultrasound of the breast may be indicated to rule out a breast abscess. Treatment includes analgesics, warm compresses, and continued emptying of the breast. Antibiotic choice includes dicloxacillin, cephalexin, or clindamycin (if penicillin-allergic). For individuals with increased risk of methicillin-resistant S. aureus (MRSA), clindamycin or trimethoprim-sulfamethoxazole can be used. Sulfa-containing drugs should not be used in mothers who are nursing newborns due to risk of kernicterus.

References:

  1. Dobiesz VA, Robinson DW. “Drug Therapy in Pregnancy.” Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Chapter 180; p 2277-2295.e3
  2. Breastfeeding and Maternal Medication Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs
  3. Manual on Contrast Media. American College of Radiology. 2017
  4. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: a reference guide to fetal and neonatal risk. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2008
  5. Practice Advisory on Codeine and Tramadol for Breastfeeding Women. American College of Obstetrics and Gynecology. April 27, 2017.
  6. Hang BS. “Breast Disorders.” Tintialli’s Emergency Medicine. 8th ed. Chapter 104.