Network Five: Emergency Medicine Case Series

Network Five: Case 1

Panel: Pramod Chandru and Shreyas Iyer.

Case Summary:

  • 61-year-old male presenting with 2 distinct episodes of shortness of breath, chest pain, and associated presyncope.  
  • Asymptomatic by the time of arrival to the emergency department.  
  • ECG and observations at triage were unremarkable. 
  • No recent travel or recent major surgeries. 
  • Initial troponin and serial troponin were 80ng/L.  
  • D-dimer was ordered given static troponin and the nature of symptoms: 0.58. 
  • Although this D-dimer was negative when age-adjusted, a V/Q scan was pursued as the patient was not felt to fit a ‘low risk’ pre-test probability for PE (IV contrast shortage dictated V/Q over CTPA). 
  • Bilateral segmental pulmonary PE identified on V/Q scan with mild right heart strain evident on subsequent CTPA and TTE.  

Key Discussion Points:

  • If a case does not follow the usual ‘pattern’ of your initial diagnosis, consider alternate aetiologies. 
  • There are many tools available for risk-stratifying PE including PERC, age-adjusted D-dimer, and the YEARS diagnostic pathway. However, the way in which to appropriately utilize these tools is nuanced.  
  • A paper published in JAMA in December 2021 demonstrates some ways in which these tools can be used together (see first reference below).  
  • The PESI score (even prior to definitive diagnosis) can be useful to risk stratify patients with possible PE and help determine their disposition.  

Take-Home Points:

  • Pre-test probability is incredibly important, particularly in entities such as PE where only highly invasive imaging modalities are diagnostic. 
  • Having a structured approach to protect yourself from your own mistakes is extremely important (such as a hypothesis and hypothesis testing approach). 

References & Background Reading

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Network Five

Emergency Medicine

Network Five Journal Club Podcast 1500 2

FACEM in Westmead and Nepean Hospitals in Sydney, Australia. Lead on Network Five Emergency Medicine Journal Club. I have a special interest in medical education, research and simulation.

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