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WELLS Criteria for Pre-test Probability of PE WELLS Criteria for Pre-test Probability of PE DVT PE Provoked 3 months 3 months Unprovoked Extended therapy (> 6 months) unless high-risk for bleeding Extended therapy (> 6 months) unless high-risk for bleeding Recurrent Extended therapy (> 6 months) unless high-risk for bleeding Extended therapy (> 6 months) unless high-risk for bleeding ACR appropriateness, background and radiation ACR APPROPRIATENESS CRITERIA: Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. http://www.acr.org/Quality-Safety/Appropriateness-Criteria (or…Google ACR Appropriateness Criteria) Relative Radiation Level - RRL Adult Effective Dose Estimated Range Pediatric Effective Dose Estimated Range Example Examinations 0 0 mSv 0 mSv Ultrasound; MRI ☢ <0.1 mSv <0.03 mSv Chest Radiographs; Hand Radiographs ☢☢ 0.1-1 mSv 0.03-0.3 mSv Pelvis Radiographs; Mammography ☢☢☢ 1-10 mSv 0.3-3 mSv Abd CT; Nuc Med Bone Scan ☢☢☢☢ 10-30 mSv 3-10 mSv Abd CT with and without; PET Scan ☢☢☢☢☢ 30-100 mSv 10-30 mSv CTA chest abd pelvis with contrast; TIPS The Relative Radiation Level for some of the exams cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (ie. Region of body exposed to radiation, imaging guidance used, etc) EFFECTIVE DOSE: Estimate of GENERIC risk to a generic individual (both sexes, all ages, standard-sized patient) and doesn’t represent the actual risk for any one individual. EFFECTIVE DOSE: US residents receive an average dose of: - 3.1 mSv - Background Environment - 3.1 mSv – Average Medical imaging Effective dose of: - 15 mSv – CT Angiogram Thorax - 2.2 mSv – V/Q Scan Special Scenarios • • • Pregnancy Poor Renal Function (Elevated Cr, TXP, etc) Contra-indication to Anticoagulation treatments PREGNANCY AND POST PARTUM: Post partum/Breast feeding Pregnant CT PE V/Q Mother Baby Dose Nominal Dose Mother Baby Dose Dose (It’s Complicated) CT PE V/Q Mother Mother Dose Dose Breasts are 4x more sensitive to radiation during pregnancy and breast feeding. Poor Renal Function (Elevated Cr, TXP, etc) Lower Extremity Ultrasound V/Q Labs &/or Treatment Anti-Coag IVC DVT & Contra-indication to Anticoagulation: Medicare Reimbursement: PE CT: Approximately $282 (P-92/T-190) V/Q: Approximately $324 (P-53/T-271)