16 Feb - CPC on Pulmonary Embolism

     Code in the middle of the night, rhtyhm other than v-tach (especially PEA) think PE.  Frequently overlooked, often preventable, PE remains a leading killer of hospitalized patients.  It is missed much less often today than in the past, some speculate due to widely available CT angiography and increased clinical awareness of this condition.  Here is a recent Mayo Clinic study that found PE to an uncommon cause of Type I autopsy findings (Type I = diagnosis missed pre-mortem that would have altered outcome if treated).
     The role of using thrombolytics to treat suspected PE in the setting of a code is controversial.  The British Thoracic Society recommends its use for massive PE with hemodynamic collapse.  In these cases your diagnosis has to be clinical.  Patients stable enough to go to the scanner are too stable to use thrombolytics.  The dose, if you so choose, is 50mg alteplase given as a bolus.  In a small randomized trial of heparin vs lytics for massive PE, all 4 patients given heparin died and all given lytics lived.  This is the extent of the "high quality" data for this condition.  The way I see it, the outcome of PEA code is so bad that if PE is high on the differential push the lytics, because you might help and you can't really make things much worse at that point.
    For further reading on management and prevention of thrombosis in hospitalized patients, review the Venous Thromboembolism Prophylasis module on the Johns Hopkins hospitalist curriculum.  Requires login, but it is free.  Also linked on the links section of this blog.