Ep 113 Pulmonary Embolism Challenges in Diagnosis Part 1

The podcast addresses the complexities of diagnosing pulmonary embolism (PE), emphasizing the need to balance diagnostic accuracy with minimizing over-testing and patient harm. It questions which patients require PE workups, the utility of PERC and Well's scores, and the roles of various diagnostic tools like D-dimer, chest x-ray, ECG, and ultrasound. The discussion highlights that missed PEs often stem from a failure to consider the diagnosis rather than flawed testing. Experts advocate for detailed patient histories focusing on exertional dyspnea and fatigue, while cautioning against over-reliance on tachycardia or isolated ECG findings. They also explore the controversial role of Gestalt in assessing pretest probability and the importance of age-adjusted D-dimer in older patients.

Outlines

Part 1: Introduction, Context, and Mortality Myths

Part 2: Diagnostic Challenges and Cognitive Biases

Part 3: Clinical Indicators and Risk Factors

Part 4: Decision Rules and Over-Testing

Part 5: Physician Behavior and Post-Diagnosis Anxiety

Part 6: Standardized Algorithms and New Tools

Part 7: Advanced D-Dimer and Imaging Modalities

Part 8: Specialized Scenarios and POCUS

Part 9: Case Review and Summary

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Emergency Medicine Cases

Part 1: Introduction, Context, and Mortality Myths

00:19Pulmonary Embolism: The Emergency Medicine Brain Buster Affecting Young and Old

Pulmonary Embolism: The Emergency Medicine Brain Buster Affecting Young and Old

01:36Key Questions in PE Workup: Who, How, and Shared Decision-Making

Key Questions in PE Workup: Who, How, and Shared Decision-Making

02:36Introducing the Experts and Setting the Stage for PE Diagnosis

Introducing the Experts and Setting the Stage for PE Diagnosis

04:21Prognosis of Untreated vs. Treated PE: Challenging the 30% Mortality Rate

Prognosis of Untreated vs. Treated PE: Challenging the 30% Mortality Rate

07:31Mortality Rates, Anticoagulation Risks, and the Spectrum of PE Patients

Mortality Rates, Anticoagulation Risks, and the Spectrum of PE Patients

Part 2: Diagnostic Challenges and Cognitive Biases

11:10Missed PE: A Failure to Consider the Diagnosis, Not Diagnostic Strategies

Missed PE: A Failure to Consider the Diagnosis, Not Diagnostic Strategies

12:52Medical-Legal Aspects and Cognitive Bias in PE Diagnosis

Medical-Legal Aspects and Cognitive Bias in PE Diagnosis

15:12Who Requires a PE Workup? Challenging Pleuritic Chest Pain as a Primary Indicator

Who Requires a PE Workup? Challenging Pleuritic Chest Pain as a Primary Indicator

17:30Breathlessness and Fatigue: Key Symptoms for PE Consideration

Breathlessness and Fatigue: Key Symptoms for PE Consideration

20:03PE Mimicking ACS and the Importance of Considering Alternative Diagnoses

PE Mimicking ACS and the Importance of Considering Alternative Diagnoses

Part 3: Clinical Indicators and Risk Factors

21:30The Significance of Normalized Vital Signs in PE Diagnosis

The Significance of Normalized Vital Signs in PE Diagnosis

23:40Tachycardia at Triage: Its Role in PE Workup Decisions

Tachycardia at Triage: Its Role in PE Workup Decisions

25:01Risk Factors for PE: Identifying the Important Ones in the ED

Risk Factors for PE: Identifying the Important Ones in the ED

27:30Syncope, COPD, and PE: Examining the Data and Clinical Considerations

Syncope, COPD, and PE: Examining the Data and Clinical Considerations

29:29Generalizability of PE Studies and the Importance of Clinical History

Generalizability of PE Studies and the Importance of Clinical History

31:34The Value of Gestalt in PE Diagnosis: Clinical Impression and Experience

The Value of Gestalt in PE Diagnosis: Clinical Impression and Experience

Part 4: Decision Rules and Over-Testing

32:44PERC Rule: Balancing Sensitivity, Specificity, and Clinical Application

PERC Rule: Balancing Sensitivity, Specificity, and Clinical Application

35:09Pre-Test Probability and the PERC Rule: Achieving a Low Post-Test Prevalence

Pre-Test Probability and the PERC Rule: Achieving a Low Post-Test Prevalence

37:35Over-Testing for PE: The Bigger Problem and the Role of the PERC Rule

Over-Testing for PE: The Bigger Problem and the Role of the PERC Rule

39:19Explaining High PE Prevalence in European Cohorts and the Risk of False Positives

Explaining High PE Prevalence in European Cohorts and the Risk of False Positives

42:30CT Scans and Filling Defects: The Limitations of Diagnosing PE

CT Scans and Filling Defects: The Limitations of Diagnosing PE

44:52Accepting Missed PEs and the Problem of Over-CT Use

Accepting Missed PEs and the Problem of Over-CT Use

Part 5: Physician Behavior and Post-Diagnosis Anxiety

47:11Individual Pathways to PE Diagnosis and the Justification for CT Scans

Individual Pathways to PE Diagnosis and the Justification for CT Scans

49:30Thromboneurosis: The Anxiety Induced by PE Diagnoses

Thromboneurosis: The Anxiety Induced by PE Diagnoses

51:08Treatment Failure is Rare and Pleuritic Chest Pain After Diagnosis

Treatment Failure is Rare and Pleuritic Chest Pain After Diagnosis

Part 6: Standardized Algorithms and New Tools

52:03The Proper Trial: PERC vs. Gestalt and Generalizability to Canada

The Proper Trial: PERC vs. Gestalt and Generalizability to Canada

54:03Standardized Approach to PE Testing: All In or All Out

Standardized Approach to PE Testing: All In or All Out

55:13Two-Level vs. Three-Level Wells: Simplifying Risk Stratification

Two-Level vs. Three-Level Wells: Simplifying Risk Stratification

57:15Cutoffs for Wells and PERC: Differentiating D-Dimer Use and Rule-Out

Cutoffs for Wells and PERC: Differentiating D-Dimer Use and Rule-Out

59:31Gestalt vs. Wells: Clinical Experience and Overestimating Pretest Probability

Gestalt vs. Wells: Clinical Experience and Overestimating Pretest Probability

1:02:33Decision Support and Standardized Algorithms for PE Diagnosis

Decision Support and Standardized Algorithms for PE Diagnosis

Part 7: Advanced D-Dimer and Imaging Modalities

1:04:36Age-Adjusted D-Dimer and the YEARS Study: Promising Advances in PE Diagnosis

Age-Adjusted D-Dimer and the YEARS Study: Promising Advances in PE Diagnosis

1:06:03YEARS Criteria: D-Dimer Thresholds and Simplified Implementation

YEARS Criteria: D-Dimer Thresholds and Simplified Implementation

1:07:31YEARS Study: Concerns and the Need for Systematic Review

YEARS Study: Concerns and the Need for Systematic Review

1:10:02ED Algorithms and the Burden on Individual Physicians

ED Algorithms and the Burden on Individual Physicians

1:11:25Chest X-Ray: Diagnosing Other Conditions and Ruling Out PE