r/emergencymedicine • u/Repulsive_Knee1304 • Jul 24 '25

Advice Missed PE, patient died

Throwaway account as to be expected.

I had a younger obese smoker male patient come in recently for shortness of breath that was exertional in nature, he said it started after he recently started working out. Patient was a smoker, 1/2 pack a day. SOB Resolved upon rest. patient states that he was carrying some heavy containers at work today, and noticed the shortness of breath again. No chest pain. No diaphoreses . No fever. No lower extremity swelling. No recent uri. Perc negative. Low pretest probability. Physical exam was significant for an expiratory wheeze, diminished sounds at bases. Patient got Breathing treatments, steroids and felt better. Reexamination showed improved aerations. Patient was discharged on steroids, albuterol. EKG NSR rate of 74, t wave inversions in v1-v3. No inversion in lead 3. No st changes. Cxr portable showed poor inspiratory effort, cardiomegaly( rotational?) but read as normal by radiologist and myself. Completely stable vitals. O2 sat of 95%, no tachy. No chest pain. Sob got better. Perc negative. Patient died at home 2 days later. Someone said PE. My guilt is consuming me. How fucked am i

EKG- S1,small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. Upright axis V1-v3 t wave inversions. No previous to compare to

366 Upvotes

96% Upvoted

170 comments sorted by

View all comments

112

u/DrS7ayer Jul 24 '25

I almost wonder if the perc rule needs to be re-validated in the post-covid, obesity epidemic world we live in. I too have found some “perc negative” PEs

21

u/Baba-Yaga-X Jul 24 '25

How did you find them? Do you scan or d-dimer PERC negative patients? PERC negative, no alarm signs: I’m done.

21

u/Crunchygranolabro ED Attending Jul 24 '25

I like to think of decisions rules more of guidelines than some iron set of laws that must be obeyed.

For PE, the biggest issue that to use PERC requires patients to be low risk, and low risk by wells, Geneva, etc, relies at least in part on gestalt. If some part of my brain is saying that something seems off, it’s worth listening.

2

u/mjjacks Resident Jul 24 '25

Could you clarify that for me? I (and the bulk of my coresidents) use Geneva explicitly because it does not include gestalt like Wells does. Do you mean using the tool in the first place would be predicated on your gestalt that the patient needs to be risk stratified in the first place?

6

u/Crunchygranolabro ED Attending Jul 25 '25

Good point on Geneva. I take issue with it because in the lowest risk group incidence is <7-9% which isn’t adequate.

Adding PERC to that is partly redundant as there’s multiple aspects (HR, hemoptysis, surgery/immobilization, prior VTE, unilateral leg swelling) which overlap. You really only get a slightly more granular stratification by age (50 vs 65) and hormone use. If there are robust studies suggesting that those 2 aspects +geneva is adequate to bring incidence to <2% I’d love to see them, but it doesn’t pass the sniff test

So at the end of the day we’re still relying on something that isn’t explicitly defined by any one scoring rule.

16

u/Ok-Bother-8215 ED Attending Jul 24 '25

Just so you know, PERC is for those whose pretest probability is less than 15%. Which means you ought to risk stratify with say Wells BEFORE you apply PERC rule.

People always miss this part. It’s not just PERC neg then no PE.

4

u/Baba-Yaga-X Jul 24 '25

Look, with PERC you have a 2% false negative rate, so you will miss some PE’s. Therefor, only in low risk patients should the PERC rule be used. Wells is heavily dependant on gestalt, and needs a d-dimer. My practice is a combination of PERC and gestalt.

1

u/Ok-Bother-8215 ED Attending Jul 25 '25

Using Wells does not need a dimer. Wells is a stratification rule that gives pretest probability. You don’t need a dimer to use wells and PERC.

6

u/the_silent_redditor Jul 24 '25

I use PERC every day.

The one PERC 0 PE (that I’ve picked up) had a tiny wedge opacity on CXR.

Dimer was super high and the CT showed bilateral PE with radiological strain.

Had that dude presented prior to infarcting, I’d probably be making this post myself as I would have 100% sent him home without Dimer/CTPA.

Can’t win them all.

5

u/newaccount1253467 Jul 24 '25

Usually bounce backs.