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]
- 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.
- PERC – not validated in children
- 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
- 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?
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]
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