Adult decision rules poor proxy for diagnosing pediatric PE

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1. Adult clinical decision rules such as the Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) may miss pulmonary emboli (PE) when applied to the pediatric population. 

2. Obesity is a known risk factor for PE, but not included in Wells criteria or PERC. Half of study patients with PE had a body mass index (BMI) ≥ 25 kg/m² suggesting need for potential inclusion of obesity in clinical decision-making tools for pediatric PE.

Study Rundown: Validated clinical decision rules, such as the Wells criteria and PERC, are often used in the adult setting when evaluating the likelihood of PE. Similar criteria are not described in pediatric literature and the suitability of adult criteria to the pediatric population has not been studied. This study retrospectively applied the Wells criteria and PERC to pediatric patients diagnosed with PE, and further described clinical characteristics of these patients. Researchers found that the most common risk factors for PE included BMI ≥ 25 kg/m², oral contraceptive use, and history of thrombus without PE. However, additional criteria in the pediatric population, such as central venous catheter use or prolonged total parenteral nutrition, merit consideration. Using the Wells criteria, all patients with PE would have been labeled as low or moderate risk at initial presentation. Using PERC, most study patients would have merited additional PE work-up and some with true PE would be missed. This study is limited by its retrospective nature and the small number of criteria eligible patients included. Though a rare diagnosis in the pediatric population, PE can have significant morbidity and mortality; consequently, further analysis into pediatric-appropriate clinical criteria is suggested.

Click to read the study published today in Pediatrics

Relevant Reading: Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis

In-Depth [retrospective chart review]: Using chart records from approximately 1.2 million Pediatric Emergency Department (PED) visits to a tertiary health care system, 105 cases of PE were identified. Of these, 25 qualified for study inclusion. Exclusion criteria included PE diagnosis before arrival to the PED, direct admission to floor bypassing the PED, known history of PE, or PE as a secondary complication during a hospital stay. Wells criteria and PERC were retrospectively applied to each study patient using data from initial presentation to PED. Criteria included vital signs, which were modified by substituting pediatric normal vital signs in place of adult values. Of the enrolled 25 cases, 48% and 52% were retrospectively labeled as low and moderate risk, respectively, using Wells criteria. No patients with true PE were labeled as high risk using the Wells criteria. Using PERC at initial presentation, 84% of patients would have merited further PE evaluation, with tachycardia being the most common clinical indicator. Half of the study patients had a BMI ≥ 25 kg/m². Obesity, a known risk factor for PE, is not included in either Wells criteria or PERC and, therefore, was not considered in study analysis.

By Neha Joshi and Leah H. Carr

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