ORIGINAL ARTICLE   Open access

Italian Journal of Emergency Medicine 2020 April;9(1):2-8

DOI: 10.23736/S2532-1285.20.00002-6

Copyright © 2020 THE AUTHORS

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language: English

Pulmonary embolism diagnosis: is a standardized approach in the emergency department really effective?

Paolo PINNA PARPAGLIA ✉, Jessica FARA

Unit of Intermediate Care and Emergency Medicine, Sassari University Hospital, Sassari, Italy

BACKGROUND: Acute pulmonary thrombo-embolism is one of the most challenging diagnosis for emergency physicians. Since its clinical presentation could be misleading, clinicians often exceed in ordering unnecessary as well as sometime risky examinations, albeit without eliminating misdiagnosis risk. Major scientific societies best practice advice, recommend pre-test probability estimate before ordering computed tomography pulmonary angiography (CTPA) for PE suspect, owing to maximize its diagnostic power without losing in clinical safety. For the purpose, well-validated decision tools have therefore been suggested. Whether a decision-tool based standardized diagnostic work-up performs better than a clinician-judgment-oriented liberal approach (gestalt approach), in achieving PE diagnosis/exclusion in the emergency care setting, is matter of debate.
METHODS: We compared two such diagnostic approaches in our emergency department (ED), matching a perspective selected (standardized approach) with a retrospective selected (liberal approach) cohort of patients, who eventually underwent CTPA with the same indication, namely PE suspect.
RESULTS: Standardized decision-tool algorithm significantly decreased diagnostic time (P=0.048) and ED staying, although not significantly (P=0.069), likely reducing misdiagnosis and over-diagnosis risk, as compared to clinician gestalt approach. Moreover, the standardized PE diagnostic algorithm allowed a convenient total exams reduction, in accordance with guidelines recommendations.
CONCLUSIONS: The study showed a superiority of the evidence-based standardized algorithm over the clinician judgment guided approach as PE diagnostic pathway in an always crowded ED.

KEY WORDS: Pulmonary embolism; Fibrin fragment D; X-ray computed tomography; Angiography; Diagnostic imaging