emDocs - March 10, 2014 - By Jason West
"Teaching Points
- The PERC rule cannot be a substitute for gestalt.
- Gestalt or some form of risk stratification should be employedfirst before using the PERC rule.
- The PERC rule should not be used in isolation to rule out PE inpregnant or postpartum patients.
- It is unclear if patients on beta blockers can be included in the PERC rule, and this significance has yet to be borne out in the data.
- The meta-analysis pooled negative LR is 0.17, which gives you a maximum pretest probability of about 15% to apply the PERC rule to risk stratify your patient down to the standard risk of 2%. However, your PE prevalence must be 7% or less (essentially aWells < 2) before the PERC rule can be applied to patients presenting to ED with suspected PE in conjunction with clinical judgment to identify patients with a prevalence of PE that is below the 1.8% test threshold proposed by Kline.
- In high PE prevalence populations (which based on the literature, seem to be in Europe) the PERC score inclusive patients will not be able to have a post-test probability at or below the accepted standard risk level.
- The only evidence we have about PERC rule-inclusive CT-PE or V/Q positive patients suggests that 56% of those will havepleuritic chest pain, which is not in a validated clinical decision rule despite having a higher OR for PE than hemoptysis and recent immobilization, which are both included in the Wells score."
http://www.emdocs.net/perc-rule-application-limitations/
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