Congrats, Maimo Fam! You ordered the correct CT and you subsequently found that Pulmonary Embolus (PE). ...Now what?
This POTD was requested for further discussion on risk stratifying patients that can potentially be discharged with a pulmonary embolus. Let's talk about the PESI Score!
Pulmonary Embolism Severity Index (PESI)
The PESI is designed to risk stratify patients who have been diagnosed with a PE in order to determine the severity of their disease. This can help physicians make decisions on the management of those patients who could potentially be treated as out-patient, as well as raise concern for those who are determined to be high-risk and could benefit from higher levels of care.
In the setting of a patient diagnosed with PE, the PESI can be utilized to determine mortality and long term morbidity. For those determined to be very low risk (score ≤ 65), all studies showed a 30-day mortality <2%. In the validation, low risk (Class I and II) had a 90-day mortality of 1.1%. The non-inferiority trial demonstrated Class I and II could have been treated as outpatients assuming no other issues.
Sounds great, but what's the catch? Although the PESI tool has been externally validated, there are a few pitfalls to be aware of.
In the setting of a patient with renal failure or severe comorbidities, clinical judgement should be used over the PESI, as these patients were excluded in the validation study.
The PESI score determines risk of mortality and severity of complications.
The score does not require laboratory variables.
It is meant to aid in decision making, not replace it. Clinical judgement should always take precedence.
The PESI score determines clinical severity and can influence treatment setting for management of PE. Class I and II patients may possibly be safely treated as outpatients in the right clinical setting.
Class I - Scores ≤ 65 indicate very low risk.
Class II - Scores of 66-85 indicate low risk.
Class III - Scores of 86-105 indicate intermediate risk.
Class IV - Scores of 106-125 indicate high risk.
Class V - Scores >125 indicate very high risk.
Again, studies show PE patients with PESI class I or II seem safe to manage as outpatients. But as always, cOrReLaTe ClInIcAlLy.
Some final thoughts:
Social situation should also be taken into account before considering outpatient management (including the appropriate administration of anticoagulants).
Given low mortality of low risk PE, outpatient management would save significant funds over hospitalization (cited as $4,500 per avoided admission).
The non-inferiority trial showed successful and safe outpatient management of Class I and II patients.
As with other tools and scores we use in the ED, use your gut and your clinical judgement. These tools are to help you in your decision, but you're the only one that can put all the pieces of your patient's clinical puzzle together. I have faith in all of you to do what's best for your patient.
References:
Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041-1046.
https://www.mdcalc.com/pulmonary-embolism-severity-index-pesi
https://wikem.org/wiki/Pulmonary_embolism