Subsegmental PE From EM Quick Hits 42 – Subsegmental PE, Trauma Analgesia, Near-Drowning, Polio, Head-up CPR

In this post, I link to and review the section on Subsegmental PE from EM Quick Hits 42 – Subsegmental PE, Trauma Analgesia, Near-Drowning, Polio, Head-up CPR.*

*Helman, A. Rezaie, S. Petrosoniak, A. Khatib, N. Reid, S, Swaminathan, A. EM Quick Hits 42 – Subsegmental PE, Trauma Analgesia, Near-Drowning, Polio, Head-up CPR. Emergency Medicine Cases. September, 2022. September 18, 2022

All that follows is from the above resource.

Topics in this EM Quick Hits podcast

Salim Rezaie on venous thromboembolism recurrence in subsegmental pulmonary embolism (1:23)

Andrew Petrosoniak on pain management in the polytrauma patient (6:44)

Nour Khatib on rural case on management of near-drowning patient (17:09)

Sara Reid on polio primer (24:30)

Anand Swaminathan on head-up cardiopulmonary resuscitation (32:20)

Best of REBEL EM: Venous thromboembolism recurrence in subsegmental pulmonary embolism

  • The management of subsegmental PE is controversial as some believe anticoagulation is unnecessary, while others claim that there is a high risk of recurrence, necessitating the use of anticoagulation
  • Clinical question: what is the risk of recurrent venous thromboembolism (VTE) in patients with subsegmental PE without DVT, without anticoagulation?
  • SubSegmental Pulmonary Embolism Study (SSPE) is a multicenter prospective cohort study with 266 ED patients enrolled from 2011-2021; patients with newly diagnosed subsegmental PE were included while those with DVT, active cancer, history of VTE, supplemental O2 requirements, pregnant, already anticoagulated or hospitalized were excluded from the study; primary outcome was recurrent VTE within 90 days.
  • 8/266 (3.1%, 95% CI 1.6-6.1%) patients had a recurrence of VTE, 4 with DVT and 4 with PE. 2 patients (0.7%, CI 0.2 – 2.9%) had major bleeding and 4 (1.4%, CI 0.6 – 4.0%) had minor bleeding.
  • There was a higher than expected level of recurrent VTE but no patients with recurrent VTE had a fatal PE. The rate of major and minor bleeding was relatively low.

Bottom Line: In patients with isolated subsegmental PE without additional risk factors, it is reasonable to make a shared decision with the patient regarding anticoagulation based on this study.

Commentary: If a thrombosis/hematology or internal medicine clinic follow-up appointment within a week or two can be secured, it is reasonable to anticoagulate all patients with symptomatic subsegmental PE without contraindications to anticoagulation until their follow-up, as the risk of major bleeding when anticoagulated for only 1-2 weeks approaches zero.

  1. Le Gal G et al. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation: A Multicenter Prospective Cohort Study. Ann Intern Med. 2022.
  2. Propersi, M. (2022, July 28). VTE recurrence in Subsegmental PE: What’s the risk? REBEL EM – Emergency Medicine Blog.


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