Pulmonary Embolism

Red Flags

Last week we discussed a basic look at Chest Pain in children presenting to the ED. This sparked several questions about Pulmonary Embolism in children. Let us take a little more specific look at PE in kids.

Pulmonary Embolism: Rare but Real

  • National Hospital Discharge Survey – 0.9 / 100,000 children per year
  • Venous thromboembolism rates have increased over the past 2 decades. [Boulet, 2012; Raffini, 2009]
    • Consideration and detection of the condition has increased.
    • Increase use of intravascular devices (ex, central lines, PICC lines).
  • Typically found to have a bimodal distribution with highest rates found in: [Stein, 2004]
    • Kids 0-1 year of age
    • Kids 15-17 years of age
  • Mortality rate – Up to 20% with 1st diagnosis, up to 30% with recurrence

 

Pulmonary Embolism: Red Flags

  • Risk stratification tools:
    • PERC – not validated in children
      • When PERC was applied RETORSPECTIVELY, 84% would have been missed. [Agha, 2013]
    • Wells Criteria – not validated in children
      • Even when Wells Criteria has heart rate adjustments for age, there is still not a statistical difference between PE (+) and PE (-) children. [Biss, 2009]
    • D-Dimer
      • Not validated as a diagnostic tool in children [Biss, 2009]
      • Can be used in adolescents
      • D-Dimer may vary with age and, hence, test threshold levels are not yet known.

 

  • Diagnosis of Pulmonary embolism is challenging in adults, it is even more so in children… so remain vigilant (while being reasonable).
  • Risk factors for thromboembolic disease in children:
    • Obesity (50% in Agha, 2013 study]
    • Oral Contraceptive Use [38% in Agha, 2013 study]
    • Central Venous Catheter
    • Cancer
    • Congenital Heart Disease
    • Prothombotic States
      • Protein C and S Deficiency
      • Antiphospholipid Antibiodies
      • Nephrotic Syndrome
      • Systemic Lupus

 

Moral of the Morsel

  • The rarity of the condition can lead to complacency; remain vigilant.
  • The lack of validated decision rules may lead to over-testing; be reasonable.
  • Always actively look for Red Flags!
  • Always reconsider the Differential Diagnosis for the patient that returns for similar complaints… does the child really have a repeat “atypical pneumonia” or is it a pulmonary embolism?

 

References

Agha BS1, Sturm JJ, Simon HK, Hirsh DA. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013 Oct;132(4):663-7. PMID: 23999960. [PubMed] [Read by QxMD]

Patocka C1, Nemeth J. Pulmonary embolism in pediatrics. J Emerg Med. 2012 Jan;42(1):105-16. PMID: 21530139. [PubMed] [Read by QxMD]

Boulet SL1, Grosse SD, Thornburg CD, Yusuf H, Tsai J, Hooper WC. Trends in venous thromboembolism-related hospitalizations, 1994-2009. Pediatrics. 2012 Oct;130(4):e812-20. PMID: 22987875. [PubMed] [Read by QxMD]

Biss TT1, Brandão LR, Kahr WH, Chan AK, Williams S. Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism. J Thromb Haemost. 2009 Oct;7(10):1633-8. PMID: 19682234. [PubMed] [Read by QxMD]

Raffini L1, Huang YS, Witmer C, Feudtner C. Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics. 2009 Oct;124(4):1001-8. PMID: 19736261. [PubMed] [Read by QxMD]

Stein PD1, Kayali F, Olson RE. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004 Oct;145(4):563-5. PMID: 15480387. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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