Title: Pulmonary Embolism: 7 Steps to Enlightenment!
题目: 肺动脉栓塞：七步程序的启示
Author 作者: Rob Rogers, MD

1. Decreasing testing for pulmonary embolism (PE)
减少肺动脉栓塞（PE）的检查
a. PERC rule (PE Rule-out Criteria) 排除PE标准（PERC原则）
If a patient is PERC negative, there is a 0.3% chance of them having a PE
如果一个病人的PERC
Unfortunately the test is not being used appropriately
不幸的是，这个标准没有被合理应用。
If there is a low gestalt for PE, use PERC
如PE的临床可能性低，要应用PERC
If there is a higher risk of PE, PERC are not applicable
如PE的临床可能性高，不需要用PERC
b. Risk of radiation is high 放射性危害是很大的
1 radiation-induced malignancy for every 2000 pulmonary CT scans
每2千个肺部CT扫描会造成一个由放射引起的恶性肿瘤
c. Risk of contrast-induced nephropathy (CIN) 造影剂导致的肾病（CIN）
1 case of CIN per 200 CT scans with IV contrast
每200个静脉造影剂的CT扫描会由一个CIN病人
2. Seven step program 七步程序
Step 1 – Accept that we cannot identify every PE
第一步－承认我们不可能明确诊断每一个PE
Step 2 – Recognize that every strategy to detect PE does harm
第二步－要知道所有诊断PE的检查都是有害处的
Step 3 – Risk stratification and reduce testing
第三步－危险因素分析，减少检查
a. Low-risk patients should have PERC rules applied
可能性低的病人应使用PERC
b. Don’t initiate diagnostic workups on people who you don’t think have a PE
如你认为病人没有PE，不要做诊断性的检查
Step 4 – Try watchful waiting
第四步－可密切观察病人
a. Place patients in obs or have them return to ED or follow up with primary care physician in 24 hours to see if they are improved and then initiate testing
观察病人或在24小时内回到急诊室或家庭医生随诊，如没有好转要进行诊断性检查
b. Document re-evaluation especially an actually counted respiratory rate
对再观察病人要有记录，尤其是要认真数呼吸频率
Step 5 – Document the medical decision making
第五步－记录你的决策根据
a. Document why we don’t think it is a PE and why it is not being worked up
记录为什么你认为病人没有PE和你没有做进一步检查的原因
b. Document the leg exam as well as the pulmonary exam
记录腿和肺部的检查
Show that you thought about if a DVT was present and there were no clinical
signs of a DVT present
显示你想到了病人有DVT或没有DVT的临床表现
Step 6 – Be less afraid of litigation
第六步－不要太恐惧法律诉讼
a. Be thorough in the history and physical exam 病史和查体一定要完整
b. Be nice to your patients 对病人一定要友好
Step 7 – Spread the word
第七步－做好宣传工作
a. Teach our learners about whittling down the testing for PE
教育我们的学生要减少不必要的对PE的检查
b. Teach them about the risks of excessive testing
让他们知道过度检查的危害

References 参考文献:
1. Singh B, Parsaik AK, Agarwal D, et al. Diagnostic accuracy of pulmonary embolism rule-out-criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012; 59: 517-520.
2. Green SM, Yealy DM. Right-sizing testing for pulmonary embolism: recognizing the risks of detecting any clot. Ann Emerg Med. 2012; 59: 524-526.
3. Vinson DR, Zehtabchi S, Yealy DM. Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review. Ann Emerg Med. 2012;60: 651-662.