Chest CT before ED discharge to prevent pulmonary embolism
In the emergency department (ED), it has become common practice to treat deep venous thrombosis (DVT) "below the knee" with enoxaparin (Lovenox) injection prior to discharge, followed by warfarin (Coumadin) at home.
Since up to 50% of patients may have associated pulmonary embolism (PE), not all of them symptomatic, should it also be common practice to do a chest CT on all of these patients prior to discharge from the ED? Given the radiation exposure associated with CT, would it be preferable to admit these patients for observation and treatment? — Dawn Riesett, PA-C, Frederick, Md.
In the ED setting for DVT, a negative d-dimer rules out a PE. If the d-dimer is elevated, consider a chest CT with PE protocol or VQ scan. However, home treatment with subcutaneous enoxaparin 1 mg/kg SQ b.i.d. while warfarin becomes therapeutic is appropriate. Consider cost, radiation exposure and risk of PE.
The newest anticoagulants are dabigatran (Pradaxa) and rivaroxaban (Xarelto). Rivaroxaban is currently approved for DVT prophylaxis, whereas dabigatran is for thromboembolism and stroke prevention. — Maria Kidner, DNP, FNP-C (158-2)