Barts and The London NHS Trust PULMONARY EMBOLISM (Rule out)

Date ________ Time _______ ED admitting consultant _____________ Tick / Cross

Inclusion Criteria Pleuritic chest pain Normal clinical examination Normal CXR Wells Criteria: Low Intermediate pre-test probability o o o o o o o Score < 2 points 2-6 points > 6 points Clincial signs of DVT No alternative diagnosis HR > 100 Immobilization / surgery last 4W Previous DVT / PE Malignancy Haemoptysis TOTAL: PE probability 2.0-3.5% 19-20.5% 50-66.7% Points 3.0 3.0 1.5 1.5 1.5 1.0 1.0_

Risk stratification / Pre-test probability Low Intermediate High

Wells 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

Investigations Baseline: 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 o o o o Temp > 38C HR < 60 or > 100 RR < 10 or > 20 Systolic BP < 100 or > 180 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

Referral / Consultation In-patient team: Team _________________________ Time referred _________ Reason for referral: Bleep ___________ Time seen __________

Fast Response Team: Nurse consultant Social Work Physiotherapy Occupational Therapy Time referred _________

Time seen __________

Created by Ling Tan Last modified on 16/1/06

ASSESS CLINICAL PROBABILITY

High (D-Dimer N/A) Intermediate (D-dimer N/A) Low D-dimer (Novocard)

D-Dimer Positive Negative

Abnormal CXR or cardiorespiratory disease? (Start LMWH) NO YES V/Q scan* 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

ROYAL LONDON HOSPITAL CLINICAL DECISION UNIT Rule-Out PULMONARY EMBOLUS DISCHARGE SUMMARY
Pt Sticker 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 __________