Prediction of pulmonary embolism in children
Commeree, Ashlee N.
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Background: Pulmonary embolism (PE) is a rare condition associated with high morbidity and mortality in children. The diagnosis of PE in children is challenging, considering the often non-specific clinical signs and symptoms associated with this condition. Computed tomography with pulmonary angiography (CTPA) is currently the diagnostic gold standard, but carries the risk of radiation-induced malignancy. For these reasons, the optimal diagnostic management strategy for the care of children with suspected PE in the emergency department (ED) setting is undefined. Objectives: We sought to describe associated clinical signs and symptoms and developed a clinical decision rule for the evaluation of children with suspected PE in the ED setting. In addition, we evaluated the Modified Wells Criteria and PERC (Pulmonary Embolism Rule-out Criteria) Rule by applying these established adult clinical decision rules against our population of children diagnosed with PE. Methods: We conducted a retrospective cohort study of children less than 21 years of age undergoing diagnostic imaging for evaluation of PE from 2000 to 2012. We included children who received either a CTPA or ventilation-perfusion (V/Q) scanning for the evaluation of suspected PE. PE was defined by evidence of an occlusion in a pulmonary blood vessel or intermediate to high probability of PE reported in the diagnostic study results of the CTPA or V/Q scan, respectively. We additionally required the use of anticoagulant therapy to establish the diagnosis of PE. Results: Among 152 patients who presented to an ED setting, the prevalence of PE was 16.4%. The most frequent presenting symptoms in children with PE were chest pain (76%) and shortness of breath (44%), while the most common risk factors were presence of a CVC (16%), prolonged immobility (20%), and recent surgery (24%). The current use of oral contraceptive pill (P value = 0.010), abnormal lung exam (P value = 0.021), and oxygen saturation level (P value = 0.003) were all significant findings that were more likely to be present in patients with PE. Conclusion: Our results describe a high risk population of children evaluated for PE presenting to an ED setting. We identified several historical, clinical, and physical exam findings that are independently associated with diagnosis of PE, such as current use of OCPs, abnormal lung exam, and oxygen saturation level. Next steps will be to use our descriptive analysis to develop a clinical decision rule for the evaluation and diagnosis of PE in children in an ED setting.
Thesis (M.A.)--Boston University