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I wanted to add some pearls from Dr. Strayer on Anita’s case from today:

* The literature and expert consensus have evolved over the past decade to favor anticoagulation for below the knee (distal or calf) DVTs. The classic teaching has been that distal DVTs are benign, so ultrasonographers often do not routinely evaluate the calf veins. Because this is no longer thought to be true, consider requesting calf vein assessment if you are suspicious.

* The finding of superficial venous thrombosis warrants a search for DVT. The treatment of superficial vein thrombosis is controversial and ranges from NSAIDs to compression stockings to anticoagulation. There is no consensus on treatment–the key EM issue is to rule out DVT.

* Patients who are moderate or high risk for DVT should be anticoagulated while awaiting ultrasound. If a DVT precipitant is not clear, consider calling hematology to inquire about hypercoaguable state labs to send before administering heparin.

* Many patients with DVT are optimally managed as an outpatient with daily LMWH shots. Visiting nursing services can help.

* Our interface with outside referring physicians is complex, and navigating their requests is fraught with pitfalls. If you don’t agree with their plan, the best course of action is usually an attempt to harmonize over the phone.

Wise words.

If you missed Sohan’s last lecture as a resident, the June 4th  Journal Club, well, here’s a brief recap. For those of you who were there for his tour-de-force, you’ll no doubt want to refer to these notes from his talk in your future practice.

Sohan discussed the original PERC rule derivation paper and its recent validation — the papers below are accessible using our password system:

Kline JA, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55. (PMID: 15304025)

Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80. (PMID: 18318689).

Sohan started with a lit review, going back to DeBakey’s 1954 discussion of 3 million PE’s, where it was first noted that PE is tough to diagnose and its prevalence is unclear. Even now, very little has changed. We don’t know the true incidence, we don’t know how many we miss, we don’t know which PE’s are clinically relevant, and we don’t know when to pursue this diagnosis. Even the Well’s criteria, which I mentioned here a couple of years ago, are not too clean — because they give more points to the physician’s judgment than to any other sign or lab result.

So we’ve been left with the unfortunate, all-to-common situation of considering D-dimers for every poor patient who presents with vague chest discomfort or dyspnea. If that dimer is positive, and it often is falsely so, we’re forced down a road of angiography , contrast, radiation, and other potential sources of morbidity.

Is there a way out of this? Is there a simple decision rule we can apply, at the bedside, using nothing but history and physical, to prevent this unnecessary testing?

Kline et al thought so — and the rule they proposed is discussed below.

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This month’s journal club presentation began with what I believe was a discussion of blood clots in Cro-Mags before touching upon late 19th century versions of CPR, the landmark closed-chest cardiac massage paper, and eventually, a comparison of ROSC (return of spontaneous circulation) in real patients vs. as seen on television. Chad then led the group in a discussion of a new meta-analysis by Xin Li et al appearing in a recent issue of Resuscitation (2006: Vol 70, pp31-36) on the topic of CPR with and without thrombolytics.

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Annals was mostly about airway this month, and felt a little sparse (Levitan showed that BURP and cricoid pressure worsen the view compared to bimanual laryngoscopy– stop the presses! Also, a letter to the editor advocated for the mnemonic LEMONS over LEMON — the extra S is for O2 saturation, which of course you might otherwise fail to consider as you're prepping to intubate… sheesh).

So, instead, I thought I'd hit up that other noteworthy periodical, the New England Journal of Medicine. This week (June 1, 2006, Vol 354, No. 22) they've got an article (pdf) from the PIOPED II study about the diagnostic value of CT angio alone, vs. CT angio plus CT venography of leg veins.

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