CEM6059-Pulmonary-embolism---rule-out-protocol-(Barts).pdf

7/29/2019 CEM6059-Pulmonary-embolism---rule-out-protocol-(Barts).pdf

1/5

Barts and The London NHS Trust

PULMONARY EMBOLISM (Rule out)

Date ________ Time _______ ED admitting consultant _____________

Inclusion Criteria Tick / Cross

Pleuritic chest pain Normal clinical examination Normal CXR Wells Criteria: Low Intermediate pre-test probability

Points

o Clincial signs of DVT 3.0o No alternative diagnosis 3.0o HR > 100 1.5o Immobilization / surgery last 4W 1.5o Previous DVT / PE 1.5o Malignancy 1.0o Haemoptysis 1.0_

TOTAL:

Score PE probability Risk stratification / Pre-test probability< 2 points 2.0-3.5% Low

2-6 points 19-20.5% Intermediate

> 6 points 50-66.7% HighWells et al Derivation of a simple clinical model to categorise patients probability of PE: Increasing the models utility with the

SimpliRed D-Dimer. Thromb Haemost 2000; 83:416-20

Likely to be discharged within 12 hrs CDU transfer form filled out

Exclusion Criteria Unstable vital signs High clinical probability of PE (refer to medics) Diagnosis unclear Pregnancy Severe chest pain Contraindication to anticoagulation Known DVT / PE on anticoagulation Major co-morbidity requiring in-patient admission


2/5

InvestigationsBaseline:

FBC, U&E, LFT (consider ABG if )(Consider: hypercoagulation screen if clinically indicated prior to

giving anticoagulation )

CXR ECG Doppler U/S legs only in patients with clinical suspicion of DVT

Subsequent investigations:

Only if Low clinical probability: D-dimer Mod High clinical probability:

V/Q (if normal CXR) or CT PA (if abnormal CXR)

(See Diagram)

Management:

Analgesia as prescribed Subsequent investigations as above

(NB: V/Q results will be available on HISS)

To be reviewed by Dr ____________ at _______ hrs Notify Medical Staff if:

o Temp > 38Co HR < 60 or > 100o RR < 10 or > 20o Systolic BP < 100 or > 180o Oxygen saturation < 92% on air

Discharge only if:

Symptoms resolving Normal / negative investigations Normal vital signs Can eat / drink normally Normal mobility Adequate home supports Discharge medications arranged Discharge letter completed


3/5

Referral / Consultation

In-patient team:

Team _________________________ Bleep ___________

Time referred _________ Time seen __________

Reason for referral:

Fast Response Team:

Nurse consultant Social Work Physiotherapy Occupational Therapy

Time referred _________ Time seen __________

Created by Ling Tan

Last modified on 16/1/06


4/5

ASSESS CLINICAL PROBABILITYHigh

(D-Dimer N/A)

Intermediate

(D-dimer N/A)

Low

D-dimer (Novocard)

Abnormal CXR or cardiorespiratory disease?

(Start LMWH)

NO

V/Q scan*YES

Intermediate

scan

PE

present

No PE

CT Pulmonary Angiogram

PE present No PE

Refer to Medics

Add Warfarin

Another Diagnosis

* Normally only the perfusion portion of the V/Q scan is done

(This service is available Mon-Fri 9-5. Outside these hours, do a CT PA)

Modified from BTS Guidelines 2003

D-Dimer

Positive Negative


5/5

ROYAL LONDON HOSPITAL

CLINICAL DECISION UNIT

Rule-Out PULMONARY EMBOLUS DISCHARGE SUMMARY

Date ___________

Dear Dr _____________

Your patient was admitted into the Clinical Decision Unit following a presentation to

the Emergency Department with chest pain &/or DIB, and was investigated for a

possible pulmonary embolus.

Tick as appropriate:

Your patient had the following investigations:

Your patient had the following management:

Your patient was observed in the CDU and discharged with the following:

TTA medications:

Out-patient referral to the medical team

(Your patient will be contacted by the Out-Patient Department)

Advice to contact yourself or the Emergency Department should there be any

further problems

Thank you

Signed _________________ Name ______________ Grade __________

Pt Sticker

Documents

CEM6059-Pulmonary-embolism---rule-out-protocol-(Barts).pdf