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Low risk for pulmonary embolism among children without tachycardia, hypoxia

The risk is low for pulmonary embolism in children with an initial suspicion of the condition who are not undergoing estrogen therapy and do not have tachycardia and hypoxia, according to a recent study.

“Although rare, the prevalence of pulmonary embolism (PE) is rising in children. Missed or delayed diagnosis of PE in children is associated with a high mortality rate of approximately 10%,” Kara E. Hennelly, MD, of the division of emergency medicine at Washington University in St. Louis School of Medicine, and colleagues wrote. “Clinical decision rules to diagnose PE have been derived and validated in adults but not for children. As a result, many adult algorithms are extrapolated for use in children.”

The researchers conducted a retrospective study and performed a recursive partition analysis to assess the accuracy and efficiency of two frequently used adult-based PE algorithms — Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) — in pediatric patients and to develop a pediatric-specific clinical decision rule for identifying PE in children and those at risk for the condition.

The study consisted of 561 pediatric patients under the age of 22 years. Participants were evaluated for PE in a hospital setting between January 2000 and April 2014 through D-dimer tests or radiologic evaluation, such as computed tomography or ventilation-perfusion scan. 

Radiologic confirmation and anticoagulant treatment was mandatory to be considered a true case of PE. Overall, 6.4% (n = 36) of patients were diagnosed with PE.

Results determined that the Wells criteria had a sensitivity of 86% and a specificity of 60%, whereas PERC had a sensitivity of 100% and a specificity of 24%.

Patients with tachycardia and an oxygen saturation of less than 95% who were also taking oral contraceptives were more likely to be diagnosed with PE. These three patient characteristics were used to create a clinical decision rule for PE that demonstrated a sensitivity of 90% and a specificity of 56%.

In addition, the clinical decision rule exhibited a positive and negative likelihood ration of 2.0 and 0.2, respectively, as well as a positive and negative predictive value of 0.12 and 0.99, respectively.

“We found that among children with an initial suspicion of PE, the risk was low (1.3%) without hypoxia, tachycardia, and estrogen therapy,” Hennelly and colleagues concluded. “Our pediatric PE clinical decision rule performs similarly to application of the Wells criteria (2%-4% risk of PE when low risk) and PERC rule (<2% when PERC negative) among adults suspected of PE. Our findings will need to be validated in other settings before they can be applied to children at risk of PE.” – by Alaina Tedesco

Disclosure: Researchers reported no relevant disclosures.