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. https://emergencymedicinecases.com/em-quick-hits-42-september-2022/. Accessed 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. https://rebelem.com/vte-recurrence-in-subsegmental-pe-whats-the-risk/