57M PMH COPD on home O2, smoker, CHF (baseline EF 30%), HTN, DM, obese (BMI 35), CKD (baseline Cr 1.6) presents to the ED with acute onset sharp, pleuritic chest pain at the right anterior chest radiating to the right axilla. Sinus tach on EKG with LVH & TWI that were present on prior EKGs. Tachypnea, O2 sat 90% on 4L NC. Afebrile. BP 127/89. A rhonchi & rales bilaterally. 3/6 holosystolic murmur throughout precordium. Obese abdomen. Bilateral LE edema pitting to the knees. Cr 2.2. WBC 12. CXR poor inspiration, bibasilar interstitial congestion, cardiomegaly, no pneumothorax, no fractures. It's a saturday night (skeleton crew - U/S tech isn't in, radiologist is tele-radiology, only one CT-tech in house with multiple emergent CTs in que). Pt has had multiple chest CTs in the past.
What's the risk of PE? Do you order a D-dimer? If you have a moderate to high suspicion for PE, do you go straight to CTPE? What about the likely delay in CT & the pt's acute on chronic renal failure? Another CT - are you worried about radiation exposure? Is there a way to spare this pt the CT?
A new study provides insight on a new diagnostic algorithm to to reduce the burden of CT for PE in the ED - if you've got the docs with the right skills! And again ALiEM provides PV Cards for easy access to relevant diagnostic & treatment rules and MDCalc helps too!
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