Pulmonary embolism workup in five steps.

A workup for pulmonary embolism (PE) is complex, with multiple clinical decision rules to remember. A proper diagnostic workup can safely rule out PE without the use of computed tomography, which is both expensive and exposes patients to radiation and intravenous contrast. However, once PE has been diagnosed, it is important to risk stratify patients according to severity to both treat and disposition them correctly. PQRsTU is a simple, easy-to-remember mnemonic for the workup of PE that considers five phases: PERC phase (PE rule-out criteria), Quantify gestalt phase (to determine proper use of D-dimer or direct to imaging), Risk stratification phase (once PE has been diagnosed), Treatment phase, and Unit or floor (patient disposition). This structured method for evaluating PE will help clinicians develop a systematic, evidence-based approach to this complex and potentially lethal disease. Video is available at https://vimeo.com/91406117 Password: perls.

Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography.

OBJECTIVE: The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT. METHODS: This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations. RESULTS: We enrolled 400 patients as a convenience sample; 71 were excluded. When a "very low" rating was considered negative and "low," "intermediate," "high," and "very high" were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively. CONCLUSIONS: Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a "very low" rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.