Residents know that d-dimer are banned when I’m in charge, but the temptation is always there.
D-dimers increase radiation. False positive d-dimers far outpace true negative d-dimers in my experience.
For patients that I consider low-risk, I just send them home, I don’t send d-dimers. There’s a sneaking suspicion that many small PEs diagnosed by the new CT scans are inconsequential and should not be treated (or found), but we don’t have proof yet.
My approach to PE begins with a decision to consider PE. There are three reasons I look for a PE – (1) unexplained dyspnea / hypoxia – this usually means a clear cxr, (2) pleuritic chest pain with PE risk factors, and (3) rarely, unexplained syncope or afib.
This patients qualifies for a PE work-up based on (2), the risk factor being post-partum. Once I decide to pursue PE, this means a CT-PE scan. A d-dimer should not be sent, this is not a low-risk patients. I only sono patients if a resident wants to practice doing sonos.
The patient had PE. She was admitted for treatment. I don’t like sending PE patients home. No one has a doctor or access to medications in my ED. The echo showed signs of post-partum cardiomyopathy, no RV strain. The patient was in the hospital for a few days and had an unremarkable stay.
It’s hard to ask a new-born mother to stay in the hospital, but you have to sometimes. If they try to run out my counsel runs along the lines of “you have to take care of yourself so that you can take care of your child.”
I have never used risk scores in PE, and yet my patients don’t die. Risk scores are like ABGs, they appear useful in vitro, but they’re useless in vivo. They may be helpful if you’ve never seen a PE before, but they’re useless to me.
As an aside, I’m not responsible for the accompanying photos to these posts… blame I.B.