COPD and PE

[paramedicmike]

Not that we can do a lot about it in the field, here's something to think about the next time you get a sick COPD-er.

Food for thought.

[BEorP]

Surprised I haven't come across this before. Interesting stuff! Does this have any implications for how you investigate COPD exacerbations, especially when there doesn't seem to be an infection or other obvious cause?

[paramedicmike]

Prehospitally? No. It doesn't. In a prehospital sense it's more mental floss than anything.

For someone I'm going to admit, however, it could possibly change some of what I'd do. I'm drawing labs anyway so why not throw a d-dimer on the the blood work? Depending on symptoms and their responses to treatment consider a chest CT.

I just saw the study yesterday so I haven't had too much discussion about it yet. I think it'd be interesting to hash this out a little more thoroughly.

[BEorP]

Thanks. Sorry, yeah "you" meant paramedicmike, PA-C in the ED. I wonder whether the D-dimer could end up leading to more confusion than clarification though given the lack of specificity?

[paramedicmike]

Well, if the dimer is negative that rules out the PE. Continue with the admission and treat the COPD appropriately. So in that sense I don't think it'll confuse anything.

If it's positive, however, I'm also looking at PERC criteria or Wells score and I'm probably going to scan them. (Kinda' hard to argue after the fact with a respiratory distress patient that I thought enough to get a dimer on why I didn't scan them when it came back positive.) Then it'll be time to consider anticoagulants and let the hospitalist doing the admission know what's up.

I've not yet looked to see if there's anything out there on how many of these patients will be positive given other comorbid factors.

[ERDoc]

1 in 4 COPDers who are admitted MAY have a PE. I'm not overly impressed yet. Of the 1 in 4 that may have a PE, how many are clinically significant? I know the study doesn't address this but I don't think I would change practice yet. Maybe future studies based on this one would persuade me. I would guess that most of your COPDers are going to have positive d-dimers due to the infection/inflammation related to their disease. Personally, I think the PERC rules are useless and don't use them anymore (yeah, my n=1 may not mean much but to think I could have missed a healthy, productive 24 y/o with multiple PEs with infarcts makes me question the PERC criteria). I would almost argue that you can't use a d-dimer in COPDers either since their pretest probability is moderate to high and d-dimers are only useful in low pretest probability pts. I think it all comes down to clinical gestalt.

[paramedicmike]

Thanks, Doc. By chance I had a discussion with my attending last night about this very topic. (Well, as a spin off from another patient on whom we were trying to rule out a PE.) He pretty much said exactly what you said.

It's definitely interesting seeing things from the ER side of the door.

[ERDoc]

You're welcome. This is the way science works. This study may not change much but it raises some more questions that may lead to additional research that changes everything.

[island emt]

That why they call it practicing medicine.

There is SO much that we don't know .

Many of the "old school" practices have been shown to have little positive effect on pt outcome as science is expanded and studies are done.

The problem with most studies, is the authors are looking for a set of answers to specific questions and in reality often discover something else they hadn't even considered.