Can Bedside Cardiac Ultrasound Better Predict the Need for Escalation of Care Compared to Computed Tomography in Patients With Pulmonary Embolisms?

Document Type

Article

Publication Date

10-1-2019

Publication Title

Annals of Emergency Medicine: An International Journal

Abstract

Study Objectives

The treatment of submassive pulmonary embolisms with systemic thrombolytics, catheter directed thrombolytics or mechanical thrombectomy (ie escalation of care) is controversial but in select patients with moderate to high risk submassive pulmonary embolisms, escalating care beyond systemic anticoagulation has been shown to be beneficial in multiple study, albeit with a potential increased risk of bleeding. The entire clinical picture, and not just one isolated vital sign or test, should be used to guide the decision to escalate care for patients with submassive pulmonary embolisms. A pulmonary embolism response team, consisting of cardiologists, interventional radiologists and emergency physicians, was developed at our institution as a multidisciplinary approach to decide on the best treatment for these patients. The ratio of the right ventricle to the left ventricle on computed tomography (CT) scan is used as a part of the criteria to decide if a patient would benefit from escalation of care. Many of these patients also receive a bedside cardiac ultrasound to evaluate for the same ratio and other signs of right ventricle dysfunction. We postulate that bedside cardiac ultrasound is a better predictor of right ventricular strain and the need for escalation of care in patients with pulmonary embolisms in comparison to CT.

Methods

This was a retrospective case review of patients who had a CT diagnosis of pulmonary embolism in the emergency department and who also had a bedside cardiac ultrasound performed and interpreted by an emergency physician (attending or resident) to compare which imaging modality better correlated with the need for escalation of care as decided by our pulmonary embolism response team. Escalation of care could include full or half dose systemic tissue plasminogen activator (TPA), catheter directed TPA, or mechanical thrombectomy. All bedside cardiac ultrasound images were archived in Q-path and were reviewed by an ultrasound fellowship trained emergency physician for quality assurance.

Results

61 patients were included in the study, 4 were excluded from analysis,3 were not candidates for escalation of care given recent neurosurgical intervention or brain metastases, and 1 had incomplete data. CT had a sensitivity of 95.45% (CI 77.16-99.88%) and a specificity of 42.86% (CI 26.32-60.65%) for predicting the need to escalate care, with a positive predictive value of 51.22 and a negative predictive value of 93.75. Bedside cardiac ultrasound had a sensitive and specificity of 90.91% (CI 70.84-98.88%) and 82.86% (CI 66.35-93.44) respectively and a PPV of 76.92 and a NPV of 93.55.

Conclusion

CT was slightly more sensitive for predicting the need to escalate care in patients with pulmonary embolisms however bedside ultrasound was more specific as CT frequency over estimated the size the right ventricle which could lead to patients receiving systemic thrombolytics or procedures unnecessarily. Patients with submassive pulmonary embolisms in the emergency department, who are being considered for escalation of care, should have an echo or bedside cardiac ultrasound done by an emergency physician to evaluate the right heart prior to escalation of care.

DOI

10.1016/j.annemergmed.2019.08.330

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