Venous thromboembolism (VTE) is a serious complication after lower limb injury and surgery. Pursuing prophylactic policies, particularly chemical prophylaxis, has been a debatable issue. In April 2007, the National Institute of Clinical Excellence recommended using chemical and/or mechanical prophylaxis for patients undergoing joint arthroplasty and other orthopedic operations. A list of risk factors predisposing patients to VTE was published. This article discusses the difficulties and methods of implementing the guidelines.

METHODS AND MATERIAL : Patients undergoing lower limb arthroplasty or treatment for femoral neck fractures were included. In total, 9893 patients required prophylactic treatment for VTE.

RESULTS : The maximum readmission rate within 3 months of lower limb arthroplasty with a deep vein thrombosis or pulmonary embolism was reduced from 70% in 2005 to 28% in 2009.

CONCLUSION : The incidence of VTE was reduced to one fifth of that before implementing the National Institute of Clinical Excellence guidelines. Thus, it has been valuable to implement the guidelines.

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Recently, some prognostic models for acute Pulmonary Embolism (PE) have been proposed. We investigated whether the Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) prognostic approach result in different prognostications.

Methods: Consecutive adult patients with acute PE were included. According to the ESC guidelines, high-risk patients were identified by the presence of shock/hypotension, intermediate-risk patients by elevated Troponin I or RVD assessed by echocardiography, and low-risk patients by the absence of any of the above. In the PESI, eleven clinical variables, easily accessible at bedside, were used to generate three risk classes. Main outcomes were all-cause and PE-related in-hospital mortality.

Results: Forty-one patients (8%,CI95% 5.8-10.8) out of 510 died. According to the ESC, 40% were at low, 54% at intermediate and 6% at high risk of short-term mortality. The distribution according to PESI was 31% (P<0.05 vs ESC), 49% and 20% (P<0.05 vs ESC) respectively. Mortality increased through the risk classes (P<0.01) without significant differences between the models. The ESC model identified with higher accuracy than the PESI both high-risk and low-risk patients (P<0.05 for both). When patients with shock/hypotension were excluded, the PESI stratified patients into classes with increasing PE-related mortality (0.7%,4.3%,11.6%, P<0.05). Troponin I and RVD added incremental prognostic value to the PESI, particularly in normotensive patients at intermediate-risk.

Conclusions: The ESC model showed higher accuracy than the PESI in identifying high and low-risk patients. In normotensive patients, the PESI could guide clinical management as well as troponin I and echocardiography testing.

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Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management.

Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist's interpretation or a confirmatory imaging study.

OBJECTIVE: We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE.

CASE REPORT: A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram.

CONCLUSION: In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.

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