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An embolized clot that travels to the lungs from the legs or, less commonly, other parts of the body (known as deep vein thrombosis or DVT) causes pulmonary embolism (PE), which is characterized by obstruction of blood flow to the pulmonary artery. As PE has the propensity to masquerade as various illnesses affecting both the cardiovascular (CV) and the respiratory system, it is crucial to identify PE at the earliest. Appropriate diagnosis of PE may lead to earlier treatment and improved patient outcomes. While pulmonary angiography remains the established gold standard for diagnosing PE, the contemporary standard of care for this condition is the computed tomography pulmonary angiogram (CTPA). Anticoagulation therapy is the fundamental strategy for managing PE, with the forefront of treatment being the use of novel and upcoming oral anticoagulants known as non-vitamin K antagonist oral anticoagulants (NOACs). The NOACs provide a practical single-drug treatment strategy, which does not hinder the patient's lifestyle and domestic responsibilities. Although PE may be fatal, early detection may lead to effective management. Despite that, mortality and morbidity associated with PE are very high in India. The awareness among Indian healthcare professionals about PE should be improved, and unified pan-country diagnostic and management guidelines should be formulated to tackle the country's PE burden.

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OBJECTIVE: Pulmonary embolism (PE) frequently requires diagnosis through CT pulmonary angiogram (CTPA). Appropriate application of evidence-based clinical decision tools can reduce unnecessary CTPAs. This study assessed adherence to and the efficacy of various aspects of the Queensland Health suspected PE diagnostic pathway, including Wells score, PE rule out criteria (PERC) and age-adjusted D-dimer interpretation. METHODS: Retrospective study of CTPAs ordered from 1 January to 30 April 2023 in a tertiary and urban ED in Southeast Queensland. Data on clinical variables, D-dimer and CTPA results were collected through medical record and radiology database review. Descriptive analyses were used to determine adherence to Queensland guidelines and performance of D-dimer interpretation tools (including comparison of age-adjusted PE with a new pre-test probability [PTP]-based model using D-dimer cut-off <1000 ng/mL for Wells score ≤4 and 500 ng/mL for Wells score 4.5-6). RESULTS: A total of 573 CTPAs were available for analysis with a 12.4% (95% confidence interval 10.0-15.4) diagnostic yield. Stratification by Wells score showed yields of 4.0%, 18.5% and 41% for low-, moderate- and high-risk patients, respectively. Twenty-five patients with low-PTP who received CTPA could have been excluded with the PERC rule. Age-adjusted D-dimer interpretation may have prevented 26 CTPAs with no false negatives, whereas PTP approach may have prevented 128 CTPAs with four false negatives. CONCLUSION: Guideline adherence can be improved, and adherence to existing clinical decision tools may reduce unnecessary CTPA ordering and increase diagnostic yield. The use of the age-adjusted D-dimer had good sensitivity, whereas the new PTP approach will require further prospective research.

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BACKGROUND: Pressure overload of the right heart (pulmonary hypertension [PH]) can be an acute or a chronic process with various pathophysiologic changes affecting the dimensions of the heart chambers. The automatic four-chamber volumetric analysis tool is now available to measure the volume of the cardiac chambers in patients undergoing a computed tomography pulmonary angiogram (CTPA). PURPOSE: To characterize the volumetric changes that occurred in response to increased systolic pulmonary arterial pressures (sPAP) in acute events, such as acute pulmonary embolism (APE), compared with other etiologies. MATERIAL AND METHODS: Consecutive patients who underwent CTPA and echocardiography within 24 h between 2011 and 2015 were included. Differences in cardiac chamber volumes were investigated in correlation to the patients' sPAP. RESULTS: The final cohort of 961 patients included 221 (23%) patients diagnosed with APE. The right (RV) to left (LV) ventricular volume ratio (VVR) was higher, while the left atrial (LA) volume index was smaller (P < 0.001) in the patients with APE. A decision tree for the prediction of APE showed that an RV to left VVR >2.8 was characteristic of APE, whereas an LA volume index >37.5 mL/m² was more compatible with PH due to other etiologies (P < 0.001). CONCLUSION: The combination of VVR and LA volume index may help in differentiating between APE and chronic PH. CTPA-based volumetric information may be used to help clarify the underlying etiology of the dyspnea.

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This study established a feature-enhanced adversarial semi-supervised semantic segmentation model to automatically annotate pulmonary embolism (PE) lesion areas in computed tomography pulmonary angiogram (CTPA) images. In the current study, all of the PE CTPA image segmentation methods were trained by supervised learning. However, when CTPA images come from different hospitals, the supervised learning models need to be retrained and the images need to be relabeled. Therefore, this study proposed a semi-supervised learning method to make the model applicable to different datasets by the addition of a small number of unlabeled images. By training the model with both labeled and unlabeled images, the accuracy of unlabeled images was improved and the labeling cost was reduced. Our proposed semi-supervised segmentation model included a segmentation network and a discriminator network. We added feature information generated from the encoder of the segmentation network to the discriminator so that it could learn the similarities between the prediction label and ground truth label. The HRNet-based architecture was modified and used as the segmentation network. This HRNet-based architecture could maintain a higher resolution for convolutional operations to improve the prediction of small PE lesion areas. We used a labeled open-source dataset and an unlabeled National Cheng Kung University Hospital (NCKUH) (IRB number: B-ER-108-380) dataset to train the semi-supervised learning model, and the resulting mean intersection over union (mIOU), dice score, and sensitivity reached 0.3510, 0.4854, and 0.4253, respectively, on the NCKUH dataset. Then we fine-tuned and tested the model with a small number of unlabeled PE CTPA images in a dataset from China Medical University Hospital (CMUH) (IRB number: CMUH110-REC3-173). Comparing the results of our semi-supervised model with those of the supervised model, the mIOU, dice score, and sensitivity improved from 0.2344, 0.3325, and 0.3151 to 0.3721, 0.5113, and 0.4967, respectively. In conclusion, our semi-supervised model can improve the accuracy on other datasets and reduce the labor cost of labeling with the use of only a small number of unlabeled images for fine-tuning.

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Background and Aim: We aimed to develop a clinical prediction model for pulmonary thrombosis (PT) diagnosis in hospitalized COVID-19 patients. Methods: Non-intensive care unit hospitalized COVID-19 patients who underwent a computed tomography pulmonary angiogram (CTPA) for suspected PT were included in the study. Demographic, clinical, analytical, and radiological variables as potential factors associated with the presence of PT were selected. Multivariable Cox regression analysis to develop a score for estimating the pre-test probability of PT was performed. The score was internally validated by bootstrap analysis. Results: Among the 271 patients who underwent a CTPA, 132 patients (48.7%) had PT. Heart rate >100 bpm (OR = 4.63 [95% CI: 2.30-9.34]; P < 0.001), respiratory rate >22 bpm (OR = 5.21 [95% CI: 2.00-13.54]; P < 0.001), RALE score ≥4 (OR = 3.24 [95% CI: 1.66-6.32]; P < 0.001), C-reactive protein (CRP) >100 mg/L (OR = 2.10 [95% CI: 0.95-4.63]; P = 0.067), and D-dimer >3.000 ng/mL (OR = 6.86 [95% CI: 3.54-13.28]; P < 0.001) at the time of suspected PT were independent predictors of thrombosis. Using these variables, we constructed a nomogram (CRP, Heart rate, D-dimer, RALE score, and respiratory rate [CHEDDAR score]) for estimating the pre-test probability of PT. The score showed a high predictive accuracy (area under the receiver-operating characteristics curve = 0.877; 95% CI: 0.83-0.92). A score lower than 182 points on the nomogram confers a low probability for PT with a negative predictive value of 92%. Conclusions: CHEDDAR score can be used to estimate the pre-test probability of PT in hospitalized COVID-19 patients outside the intensive care unit. Relevance for Patients: Developing a new clinical prediction model for PT diagnosis in COVID-19 may help in the triage of patients, and limit unnecessary exposure to radiation and the risk of nephrotoxicity due to iodinated contrast.

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PURPOSE: Ordering trends for computed tomographic pulmonary angiogram (CTPA) studies by local emergency departments were assessed, along with the impact of the COVID-19 pandemic on these ordering trends and CTPA positivity rates. METHODS: A retrospective quantitative analysis was performed on all CTPA studies ordered between February 2018 - January 2022 by three local tertiary care emergency rooms to investigate for pulmonary embolism. Data collected from the first two years of the COVID-19 pandemic was compared to the two years prior to the pandemic to assess for significant changes in ordering trends and positivity rates. RESULTS: The overall number of CTPA studies ordered increased from 534 studies in 2018-2019 to 657 in 2021-2022 and the rate of positive diagnosis of acute pulmonary embolism varied between 15.8% to 19.5% over the four years studied. There was no statistically significant difference in the number of CTPA studies ordered when comparing the first two years of the COVID-19 pandemic to the two years immediately prior; however, the positivity rate was significantly higher during the first two years of the pandemic. CONCLUSION: Over the studied period from 2018-2022, the overall number of CTPA studies ordered by local emergency departments has increased, in line with literature reports from other locations. There was also a correlation between the onset of the COVID-19 pandemic and CTPA positivity rates, possibly secondary to the prothrombotic nature of this infection or the increase in sedentary lifestyles during lockdown periods.

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OBJECTIVE: The primary objective was to quantify the prognostic association between various D-dimer thresholds and 30-day PE diagnosis among emergency department (ED) patients with suspected SARS-CoV-2 infection. METHODS: This was a retrospective study of patients enrolled in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) registry from March 1, 2020 to July 2, 2021. We included consecutive adults (≥ 18 years) presenting to 49 EDs with chest pain, shortness of breath, hypoxia, syncope, presyncope, or hemoptysis who were tested for both SARS-CoV-2 and D-dimer at index ED visit. The primary outcome measure was the sensitivity, specificity, and negative predictive value of D-dimer test thresholds for the outcome of 30-day PE diagnosis. RESULTS: Among 10,837 patients included in our study, 404 (3.7%) were diagnosed with PE at 30-days. A standard D-Dimer threshold of 500 ng/mL had a sensitivity of 97.8% (95% confidence interval [CI] 95.8-99.0%), specificity of 40.9% (95% CI 39.9-41.8%), and negative predictive value of 99.8% (95% CI 99.6-99.9%). An age-adjusted D-dimer threshold had a sensitivity of 96.0% (95% CI 93.6-97.7%), specificity of 48.5% (95% CI 47.5-49.4%), and negative predictive value of 99.7% (95% CI 99.5-99.8%). D-dimer testing had slightly lower prognostic performance among SARS-CoV-2 positive compared to SARS-CoV-2 negative patients in predicting 30-day PE diagnosis. CONCLUSIONS: Among ED patients with suspected SARS-CoV-2, the standard 500 ng/mL and age-adjusted D-dimer thresholds were comparable for the prediction of PE at 30-days. The prognostic performance of D-dimer was lower among SARS-CoV-2 positive patients. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

RéSUMé: OBJECTIF: L'objectif principal était de quantifier l'association pronostique entre différents seuils de D-dimères et le diagnostic d'EP à 30 jours chez les patients des services d'urgence suspectés d'être infectés par le SRAS-CoV-2. MéTHODES: Il s'agissait d'une étude rétrospective des patients inscrits au registre du réseau canadien de réponse rapide aux urgences COVID-19 (CCEDRRN) du 1er mars 2020 au 2 juillet 2021. Nous avons inclus des adultes consécutifs (>18 ans) se présentant dans 49 services d'urgence pour une douleur thoracique, un essoufflement, une hypoxie, une syncope, une présyncope ou une hémoptysie et qui ont été testés à la fois pour le SRAS-CoV-2 et les D-dimères lors de la visite de référence aux urgences. Le principal critère d'évaluation était la sensibilité, la spécificité et la valeur prédictive négative des seuils du test des D-dimères pour le diagnostic de l'EP à 30 jours. RéSULTATS: Parmi les 10 837 patients inclus dans notre étude, 404 (3,7 %) ont reçu un diagnostic d'EP à 30 jours. Un seuil standard de D-Dimer de 500 ng/mL avait une sensibilité de 97,8 % (intervalle de confiance [IC] à 95 % 95,8-99,0 %), une spécificité de 40,9 % (IC à 95 % 39,9-41,8 %) et une valeur prédictive négative de 99,8 % (IC à 95 % 99,6-99,9 %). Un seuil de D-dimères ajusté à l'âge avait une sensibilité de 96,0% (IC à 95 % 93,6-97,7 %), une spécificité de 48,5% (IC à 95 % 47,5-49,4 %) et une valeur prédictive négative de 99,7 % (IC à 95 % 99,5-99,8 %). Le test des D-dimères avait une performance pronostique légèrement inférieure chez les patients positifs pour le SRAS-CoV-2 par rapport aux patients négatifs pour le SRAS-CoV-2 en ce qui concerne la prédiction du diagnostic d'EP à 30 jours. CONCLUSIONS: Chez les patients des urgences suspectés d'être atteints du SRAS-CoV-2, les seuils standard de 500 ng/ml et les seuils de D-dimères ajustés à l'âge étaient comparables pour la prédiction de l'EP à 30 jours. La performance pronostique des D-dimères était plus faible chez les patients positifs pour le SRAS-CoV-2. ENREGISTREMENT DE L'ESSAI: Clinicaltrials.gov, NCT04702945.

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Background: Pyogenic liver abscess (PLA) is the most common type of visceral abscess. Its variable clinical presentation depends on patient demography, underlying conditions, causative pathogens as well as the size of the abscess. Most cases are secondary to enteric pathogens that cause focal liver disease. Gas-forming pyogenic liver abscess (GFPLA) is a rare subgroup of PLA characterized by the presence of gas within the abscess. The disease is associated with diabetes mellitus (DM) while Klebsiella penumoniae is the most frequently isolated pathogen. Despite appropriate evaluation and management, secondary complications are common with significant morbidity and mortality that necessitate prompt recognition and management. Case presentation: We present a case of a 46-year-old gentleman from Bangladesh who presented to the emergency department with fever, chills, and right upper quadrant abdominal discomfort. Evaluation revealed elevated inflammatory markers with high blood glucose and a subdiaphragmatic lucency on a plain chest radiograph. The suspected underlying visceral infection was confirmed by abdominal ultrasonography and computed tomography which demonstrated an emphysematous abscess of 8 cm in diameter in the right liver lobe.Because of clinical instability, the patient was admitted to the medical intensive care unit (MICU) where he received appropriate supportive management with antimicrobials and percutaneous drainage of the abscess. Cultures collected from blood, the abscess, and urine grew a sensitive strain of Klebsiella pneumoniae. During his stay in the MICU, he complained of dyspnea. A CT pulmonary angiography was suggestive of septic emboli. A few days later, the patient started to complain of left gluteal pain and an US revealed a deep left gluteal abscess which required drainage. Cultures of the pus grew the same sensitive strain of Klebsiella pneumoniae. After receiving 6 weeks of parenteral antimicrobial therapy a repeated US revealed complete resolution of the abscess in the liver. Outpatient follow up showed favorable recovery. Conclusion: Gas-forming pyogenic liver abscess (GFPLA) is a rare manifestation of pyogenic liver abscess that usually occurs in patients with poorly controlled DM. Despite appropriate evaluation, morbidity remains high therefore timely recognition and anticipation of complications is important.

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OBJECTIVE: The objective of this study was to assess the impact of introduction of a new pulmonary embolism (PE) diagnostic guideline with a raised D-dimer threshold. METHODS: This is a single-site, observational, cohort study with a historical comparison. The new guideline raised the D-dimer threshold to 1000 ng/mL for most patients with a Wells' score of 4 or less. Patients investigated for PE with a D-dimer level and/or definitive imaging in 6-month periods before and after the introduction of the guideline were eligible. Patients with D-dimers of 500-1000 ng/mL were prospectively followed up at 3 months for missed PE. RESULTS: During the pre-intervention period, 688 patients were investigated for PE, 366 (53.2%) received definitive imaging and 39 PE were diagnosed (5.7% overall, 10.7% of those imaged). For the 121 patients with D-dimers ≥500 and <1000 ng/mL, 87 (71.9%) were imaged with 7 (5.8%) having a PE diagnosed. Post intervention there were 930 patients, of which 426 (45.8%) received definitive chest imaging and there were 50 patients with PE diagnosed (5.4% overall, 11.7% of those imaged). For the 185 patients with D-dimers ≥500 and <1000 ng/mL, 60 (32.4%) were imaged with 5 (2.7%) having PE diagnosed. No cases of missed PE were identified at 3 months. CONCLUSION: The introduction of the new guideline was associated with a reduction in overall imaging rates without evidence of missed PE. Further evaluation in other settings is recommended.

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We describe a rare case of simultaneous idiopathic right ventricular outflow tract dilatation and idiopathic main pulmonary artery aneurysm. A 59-year-old male presented with complaints of exertional shortness of breath and a cardiac murmur since childhood. CT pulmonary angiogram showed main pulmonary artery dilatation with a diameter of 5.8 cm. Cardiac MRI revealed right ventricular outflow tract dilatation with a diameter of 5.4 cm and a main pulmonary artery aneurysm with a 5.6 cm diameter. Cardiothoracic surgery was consulted for surgical repair. Definitive management of right ventricular outflow tract dilatation and pulmonary artery aneurysms is challenging due to their infrequent diagnosis and lack of established guidelines. The treatment for central aneurysms is surgery which includes aneurysmectomy and right ventricular outflow tract repair or replacement.

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Radiofrequency cardiac ablation is increasingly performed for the management of dysrhythmias. Bleeding is a well-known complication of this procedure. We present a rare case of a near-fatal iatrogenic hepatic hemorrhage after cardiac catheter ablation. (Level of Difficulty: Advanced.).

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BACKGROUND: Current pulmonary embolism treatment options rely heavily on anatomical clot location. However, anatomical location does not necessarily determine adverse outcomes; rather, clinical severity is secondary to the degree of perfusion impairment. Dual-energy computed tomography pulmonary angiogram (DE-CTPA) can map perfusion at the time of pulmonary embolism diagnosis. Single-photon emission computed tomography ventilation-perfusion scans allow for perfusion tracking similar to DE-CTPA. METHODS: We present 3 patients with intermediate-risk pulmonary embolism treated with mechanical thrombectomy using the Inari FlowTriever System (Inari Medical, Irvine, Calif). Lung perfusion scoring was applied to pre-procedure and post-procedure imaging. We graded perfusion of each lobe in 3 planes. If the entire lobe was perfused, a score of 3 was assigned. If lung perfusion is normal, total perfusion score is 15. All patients had pre-procedure and follow-up transthoracic echocardiograms. RESULTS: All 3 patients were diagnosed with pulmonary embolism via DE-CTPA that showed right ventricle strain and had deep venous thrombosis. Following mechanical thrombectomy, patients immediately experienced improvement in perfusion score; scores continued to improve at follow-up. All patients also had improvement in right ventricle size or function on follow-up echocardiogram. DISCUSSION: Intermediate-risk pulmonary embolism often has large initial clot burden that predicts residual pulmonary vascular obstruction. Residual pulmonary vascular obstruction is associated with increased risk of death, recurrent thrombus, and chronic thromboembolic pulmonary hypertension. Clot removal via thrombectomy may decrease the prevalence of residual pulmonary vascular obstruction by improving lung perfusion. We found that mechanical thrombectomy increased lung perfusion immediately and at follow-up assessments.

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Background: A high incidence of thromboembolic phenomena has been widely reported in patients with coronavirus disease 2019 (COVID-19) pneumonia. There is, however, a paucity of data detailing the incidence and characteristics of pulmonary emboli (PE) in COVID-19 patients in the South African setting. Objectives: To describe the incidence and characteristics of PE confirmed by CT pulmonary angiogram (CTPA) in patients with COVID-19 pneumonia admitted to a tertiary hospital in the Western Cape, South Africa. Methods: This was a retrospective-, descriptive study of all adult patients with COVID-19 pneumonia confirmed by polymerase chain reaction (PCR) undergoing CTPA for suspected PE while admitted to Groote Schuur Hospital. The study period was from 01 April 2020 to 30 September 2020. Results: The study cohort consisted of 116 patients, 59% being female, of whom 29% were pregnant or in the postpartum period. The median age for both genders combined was 49.5 years. The overall incidence of PE was 19%, with 20% in our subset of pregnant and postpartum patients. The majority (64%) of PE's were reported as being segmental in anatomical location. Conclusion: The noteworthy cohort included patients with pulmonary tuberculosis (PTB), HIV as well as pregnant and postpartum patients. The overall incidence of PE was 19% with no significant differences in demographics, comorbidities or D-dimer levels between patients with or without PE. The importance of a high clinical index of suspicion together with the role of CTPA in diagnosing PE in hospitalised COVID-19 patients is emphasised.

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Pulmonary embolism remains a common and potentially deadly disease, despite advances in diagnostic imaging, treatment and prevention. Managing pulmonary embolism requires a multifactorial approach involving risk stratification, determining appropriate diagnostics and selecting individualised therapy. The first part of this article reviewed the pathophysiology, risk factors, clinical presentation, diagnostic evaluation and therapeutic management and early outpatient management of pulmonary embolism. This second part summarises pulmonary embolism in the setting of pregnancy, COVID-19, recurrent disease and chronic thromboembolic pulmonary hypertension.

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Pulmonary embolism remains a common and potentially deadly disease, despite advances in diagnostic imaging, treatment and prevention. Managing pulmonary embolism requires a multifactorial approach involving risk stratification, determining appropriate diagnostics and selecting individualised therapy. This article reviews the pathophysiology, risk factors, clinical presentation, diagnostic evaluation and therapeutic management and early outpatient management of pulmonary embolism. The second part summarises pulmonary embolism in the setting of pregnancy, COVID-19, recurrent disease and chronic thromboembolic pulmonary hypertension.

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Pulmonary artery pseudoaneurysms are uncommon and can cause severe, life-threatening haemoptysis. We present a case of a 74-year-old gentleman who was being treated for COVID-19 pneumonitis and a concomitant segmental pulmonary artery thrombus with conventional treatment and anticoagulation. The patient developed significant haemoptysis during admission. A repeat computed tomography pulmonary angiogram revealed an 8 mm left upper lobe pulmonary artery pseudoaneurysm. Anticoagulation was withheld and the pseudoaneurysm was successfully treated with endovascular embolisation with an Amplatzer® IV plug, leading to resolution of the haemoptysis. To our knowledge this is the first case of a pulmonary artery pseudoaneurysm secondary to COVID-19.

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PURPOSE: COVID-19 raises D-dimer (DD) levels even in the absence of pulmonary embolism (PE), resulting in an increase in computed tomography pulmonary angiogram (CTPA) requests. Our purpose is to determine whether there are differences between DD values in PE-positive and PE-negative COVID-19 patients and, if so, to establish a new cutoff value which accurately determines when a CTPA is needed. METHODS: This study retrospectively analyzed all COVID-19 patients who underwent a CTPA due to suspected PE between March 1 and April 30, 2020, at Ramón y Cajal University Hospital, Madrid (Spain). DD level comparisons between PE-positive and PE-negative groups were made using Student's t test. The optimal DD cutoff value to predict PE risk in COVID-19 patients was calculated in the ROC curve. RESULTS: Two hundred forty-two patients were included in the study. One hundred fifty-one (62%) were men and the median age was 68 years (IQR 55-78). An increase of DD (median 3260; IQR 1203-9625 ng/mL) was detected in 205/242 (96%) patients. 73/242 (30%) of the patients were diagnosed with PE on CTPA. The DD median value was significantly higher (p < .001) in the PE-positive group (7872, IQR 3150-22,494 ng/mL) compared with the PE-negative group (2009, IQR 5675-15,705 ng/mL). The optimal cutoff value for DD to predict PE was 2903 ng/mL (AUC was 0.76 [CI 95% 0.69-0.83], sensitivity 81%). The overall mortality rate was 16% (39/242). CONCLUSION: A higher threshold (2903 ng/mL) for D-dimer could predict the risk of PE in COVID-19 patients with a sensitivity of 81%.

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A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO2) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults (n = 111). The financial impact and harm avoidance of adding EtCO2 to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO2 was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22-8.96; P = .01). For PE exclusion, an EtCO2 cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO2, one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO2 cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.

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BACKGROUND: Fat Embolism Syndrome (FES) is a rare condition where circulating fat emboli can lead to life threatening multisystem dysfunction. Diagnosis of FES occurs mainly by exclusion. The aim of this study was to describe the injury, event details, and factors associated with the diagnosis of FES following trauma presenting to a Level 1 Trauma Centre in Melbourne, Australia. METHODS: Medical records of all patients with a complication of FES between 2006 and 2018 were retrospectively reviewed. Demographics, injury factors, hospital event details, radiological procedures and length of stay were collected. RESULTS: Thirty six patients, with median age of 26 years (IQR 19, 42) and median Injury Severity Score (ISS) of 18.5 (IQR 10, 27) were diagnosed with FES. Other associated factors included male gender (86%) and having one or more long bone fractures (97%). Of the major FES diagnostic criteria, 94% of patients experienced hypoxia, 36% had mental status changes, whereas only 11% had petechiae. Computed Tomography Pulmonary Angiogram (CTPA) was performed on 19 patients (53%) with all being negative for pulmonary embolus. Most demonstrated ground glass opacity (58%), and FES was reported as the likely cause of patient presentation in 53% of cases. CONCLUSION: FES following trauma was rare, with its diagnosis based on clinical factors including long bone fracture and hypoxia, and the exclusion of other respiratory diagnoses. CTPA was frequently used since 2008 and further research is warranted to determine if this radiological procedure can assist with more definitive diagnosis of FES.

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We describe a challenging case of a patient with MINOCA due to isolated right ventricular myocardial infarction with microvascular obstruction identified on cardiac magnetic resonance imaging. This case highlights that even a comprehensive, guideline-based assessment of these patients can initially fail to detect the underlying pathology. (Level of Difficulty: Beginner.).