Emergency Medicine is Hard

Initiation of Diagnostic Testing

• Requires at least one symptom referable to the chest
• Assess Vitals – look for tachycardia, hypoxia (<95% on RA or a new O2 requirement), tachypnea
• Assess ECG for signs of pulmonary hypertension (Tachycardia, S1Q3T3, TWI in anterior leads, incomplete RBBB)

Note: Low clinical suspicion + PERC negative predicts an outcome rate of PE <1%

PERC Rule

If PERC negative, there is <2% chance of a PE

D-Dimer Testing

• Indicated for patients with low-pretest probability; Wells score: 2-4; sRGS 2-4
• D-dimer will remain high for up to 72 hours after symptom onset
• Age-adjusted Dimer formula: Age *10 ng/mL
• All patients with a positive dimer should undergo diagnostic testing to investigate the presence of a clot

Gestalt

• Gestalt or implicit reasoning has similar diagnostic performance characteristics and inter-observer reliability as the Well’s score or RGS

Diagnostic testing Map