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Three Part Question

In a [patient with suspected pulmonary embolism] is [outpatient investigation] [safe]?

Clinical Scenario

A 38 year old man presents to the emergency department with left posterior pleuritic chest pain. He had a DVT 8 years ago and his D-dimer levels are elevated. He is haemodynamically stable with normal oxygen saturations, ECG and chest Xray. You would like to rule out a pulmonary embolism, but it is 8pm. You wonder whether it would be safe to discharge the patient home overnight before his VQ scan tomorrow.

Search Strategy

Medline 1966-04/03 using the OVID interface.
[(pulmonary embol$.mp OR exp Pulmonary Embolism OR PE.mp OR exp Thromboembolism OR pulmonary infarct$.mp) AND (diagnosis.mp OR exp Diagnosis) AND (outpatient.mp OR exp Outpatients OR clinic.mp OR exp Outpatent clinics, hospital)] LIMIT to human AND English.

Search Outcome

198 papers were found, one of which looked at outpatient investigation of patients with suspected PE.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bauld DL et al, 1999, Canada	128 emergency department patients – 50 with suspected PE, the rest suspected DVT All given one dose of dateparin and discharged overnight prior to investigations	Prospective cohort	Adverse events	6% had bruising at injection site No other adverse events relating to outpatient investigation	Small study numbers

Comment(s)

This is the only published study looking at outpatient investigation of PE and is small. Further research is needed.

Clinical Bottom Line

It may be safe to investigate selected patients with suspected pulmonary embolus at home.

References

1. Bauld DL, Kovacs MJ. Dalteparin in emergency patients to prevent admission prior to investigation for venous thromboembolism. Am J Emerg Med 1999;17(1):11-15.