EM Quick Hits 39 Overdiagnosis, Lytics for Submassive PE, Pericardial Effusion, Hemophilia Treatment

Topics in this EM Quick Hits podcast

Justin Morgenstern & Eddy Lang on the problem of overdiagnosis in EM (0:37)

Anand Swaminathan on an approach to the indications and dosing of systemic thrombolytics for submassive pulmonary embolism (27:06)

Taraha Bhate’s QI corner on pericardial effusion (33:20)

Brit Long on emergency treatment of the bleeding hemophilia patient ( part 2 of 2 part series) (40:25)

Podcast: Play in new window | Download (Duration: 52:11 — 47.8MB)

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Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Saly Halawa, Brit Long, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Lang, E. Morgenstern J. Bhate, T. Long, B. EM Quick Hits 39 – Overdiagnosis, Lytics for Submassive PE, Pericardial Effusion, Hemophilia Treatment. Emergency Medicine Cases. June, 2022. https://emergencymedicinecases.com/em-quick-hits-june-2022/. Accessed [date].

Overdiagnosis in Emergency Medicine

• Definition of overdiagnosis: Labelling a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis and can experience physical, psychological, and financial harm
• 5 main causes of overdiagnosis

1. 1. Over reliance on medical tests. A societal belief in prevention and early diagnosis, despite the general lack of evidence to support cancer screening to decrease mortality
   2. Increasingly sensitive diagnostic tests, leading to findings of of questionable importance
   3. Risk averse medical culture
   4. Expanding disease definitions and thresholds/over-medicalization of disease
   5. Pervasive financial incentives from industry

• Common ED clinical scenarios
  • Subsegmental PE – with higher resolution CTs pulmonary emboli are more prevalent than ever, yet PE mortality has not changed in decades
  • CT angiogram for suspected subarachnoid hemorrhage – leads to detection of lesions that may not be causative but may result in follow-up burden without clinical benefit
  • Exercise stress testing in low-risk chest pain has a high false positive rate with risk of needless downstream invasive testing (see Journal Jam 15 Cardiac Stress Testing for deep dive)
  • Anaphylaxis – recent increase in the incidence of the diagnosis as many patients do not meet the disease threshold, leading to costly over-prescription of epinephrine auto-injectors.
• Solutions to the overdiagnosis problem in EM
  • A collective understanding that in the pursuit of making a diagnosis in the ED diagnosis we should seek to balance our desire for a near zero miss rate with the downstream deleterious effects of overdiagnosis
  • Use shared decision making so that patients understand the problems of overdiagnosis
  • Aim to educate medical students, residents staff docs and each other about the downstream effects of overdiagnosis. The more we are collectively aware of the problems, the more likely we will be to address them.

Gilbert Welch’s landmark book Overdiagnosed: Making People Sick in the Pursuit of Health

Preventing Overdiagnosis Conference

An approach to the indications and dosing of systemic thrombolytics for patients with submassive pulmonary embolism

Despite murky evidence for IV thrombolytics in a wide spectrum of patients with submassive PE (more recently termed “intermediate risk” PE), we should risk stratify this group of PE patients and consider thrombolytics in those patients on the end of the submissive PE clinical spectrum that we anticipate might decompensate/develop shock (massive PE). For example, PE patients with soft BP, poor oxygen saturation, severe respiratory distress, very high elevated troponin, worrisome PoCUS findings for impending obstructive shock, large proximal clot burden on CTPA etc.  The risk of death from PE needs to be weighed against the risk of death from bleeding.

Dr. Swaminathan’s approach to thrombolytics and interventional radiology in patients with submassive pulmonary embolism

• HIGH risk for decompensation and LOW risk bleeding – consider alteplase 50 mg  infusion over 1 hr and repeat at the end of the infusion if no clinical improvement
• LOW risk for decompensation and HIGH risk for bleeding – consider holding off on thrombolytics and arranging for interventional radiology as catheter directed thrombolysis or embolectomy may be indicated
• HIGH risk for decompensation and unlikely to remain stable while waiting for interventional radiology – consider systemic thrombolytics
• HIGH risk for decompensation and HIGH risk for bleeding– in most cases thrombolytics are likely to portent more benefit than harm as these patients are more likely to die from PE than a bleed. Consider lower dose: alteplase 25mg over 1 hr, or a slower infusion over 2 or 6 hrs
• MODERATE risk for decompensation and LOW risk for bleed– arrange for interventional radiology, but if delay to interventional radiology consider low dose thrombolytics – alteplase 25mg infused over 1hr, repeat dose if no clinical improvement

Update 2022: An open label randomized clinical trial of 94 patients with intermediate-high risk pulmonary embolisms found that the proportion of patients with an RV/LV ratio >0.9 (suggestive of RV dysfunction) at 3 months was lower in patients who underwent catheter directed thrombolysis plus anticoagulation compared to those who received anticoagulation monotherapy, but was not a statistically significant difference (95% CI 0.06-1.69). One case of nonfatal major gastrointestinal bleeding occurred in the catheter-directed thrombolysis group. Note – this study was prematurely stopped due to the COVID-19 pandemic and underpowered. Abstract

Internet book of critical care deep dive into management of submassive pulmonary embolism

QI Corner: Uremic pericardial effusion

• Consider pericardial effusion on the differential for patients with unexplained dyspnea, especially for those at high risk for pericardial effusion
• Check the nursing notes for repeat vital signs before discharge or have a system in place where repeat abnormal vitals are flagged
• Consider a quick cardiac PoCUS in patients with shortness of breath without an obvious cause – especially dialysis patients and cancer patients who are at high risk for pericardial effusions

Emergency treatment of bleeding in patients with hemophilia (part 2 of 2 part series)

Part 1: Hemophilia Recognition & Workup

Step 1: Identify immediate life-threatening emergencies

Step 2: Control bleed at local site if possible

Step 3: Replace coagulation factors – see treatment below

Step 4: Speak with a hematologist

• Treat based on history and suspected site/severity of bleeding. Do not wait for exam, imaging, or laboratory testing to administer factor replacement.
• Major bleeds: major trauma, the airway, CNS, GI hemorrhage, bleeding in the chest, the retroperitoneum, epistaxis, and the eyes or orbits.
  • Raise factor to 100%
• Minor bleeds: muscles, joints, oral mucosa, and hematuria.
  • Raise factor to 50%.
• May use patient’s own factor replacement.
• Each unit/kg of factor VIII replacement raises factor levels by 2%, and each unit/kg of factor IX replacement raises factor levels by 1%.
  • Major bleeds in a hemophilia A patient, give 50 units/kg to reach 100%. In hemophilia B, give 100 units/kg to reach 100%.
• If concerned about bleeding and don’t know the patient’s baseline factor levels, assume the factor level is 0%. If there’s any doubt, give full factor replacement.
• Other indications for factor replacement: fracture, sprain, or dislocation, heavy menstrual bleeding with moderate to severe anemia or volume loss, need for an invasive procedure or surgery.
• If factor replacement not available, activated PCC or FEIBA can be used in hemophilia A (80-100 units/kg). Recombinant FVIIa can be used in both hemophilia A and B (90 mcg/kg IV), even if an inhibitor is present.
• Inhibitors cause multiple problems: interfere with the patient’s own circulating factors; interfere with infused factor concentrates.
  • Difficult to diagnose in the ED unless the patient knows they have an inhibitor
  • Consider in patient with recurrent or breakthrough bleeds
  • Safest treatment for those with inhibitor in hemophilia A or B is recombinant factor VIIa at 90 mcg/kg
• Non-bleeding complications: HIV, hepatitis B, hepatitis C.
  • If fever and long-term vascular access are present, consider line infection and infective endocarditis.
• Other considerations: avoid intramuscular (IM) administration of medications.

emDOCs Managing Hemophilia in the ED

None of the authors have any conflicts of interest to declare