What is the recommended management for a child with suspected pulmonary embolism (PE)?

Management of Suspected Pulmonary Embolism in Children

Children with suspected PE require prompt recognition of respiratory symptoms combined with VTE risk factors, followed by risk stratification based on hemodynamic status to guide immediate anticoagulation versus primary reperfusion strategies. 1, 2

Initial Recognition and Diagnosis

Clinical Presentation

• Maintain high index of suspicion when children present with dyspnea, hypoxemia, pleuritic chest pain, or unexplained tachycardia, particularly in the presence of VTE risk factors 1
• Diagnosis is frequently delayed (mean 7 days from symptom onset) due to low clinical suspicion in pediatrics, which worsens outcomes 1
• Common risk factors include: immobilization (38%), infection (31%), central venous lines (23%), surgery/trauma (22%), malignancy (15%), hormonal contraception/pregnancy (15%), and obesity (13%) 1

Diagnostic Approach

• CTPA is the primary imaging modality, used in three-quarters of pediatric PE cases, though judicious use is essential to minimize radiation exposure 1
• Adult clinical decision rules (Wells criteria, PERC) should be used cautiously in children, as they have not been validated in pediatric populations 1, 3
• A pediatric-specific approach suggests PE is unlikely in children without oral contraceptive use, tachycardia, or oxygen saturation <95% (sensitivity 90%, negative predictive value 0.99) 3
• Alternative imaging includes ventilation-perfusion scanning, MRI, and echocardiography when CTPA is contraindicated 1, 4

Risk Stratification and Treatment Algorithm

High-Risk PE (Hemodynamically Unstable)

High-risk PE is defined as cardiopulmonary arrest, sustained hypotension, or normotension with signs/symptoms of shock 2

Immediate management:

• Pursue rapid primary reperfusion with either surgical embolectomy or systemic thrombolysis in conjunction with heparin infusion 2
• Thrombolytic therapy was used in 29% of reported pediatric PE cases, though this may reflect reporting bias toward severe cases 1
• Provide supportive care including hemodynamic support as needed 2

Intermediate-Risk PE

Intermediate-risk PE is defined as normotension without shock, but with evidence of right ventricular strain on imaging (tricuspid regurgitation, septal flattening, RV dilation) or elevated cardiac troponin 1, 2

Management decision-making:

• The decision to pursue primary reperfusion is complex and should be reserved for patients with more severe disease within this category 2
• Catheter-based therapies may be beneficial if primary reperfusion is pursued 2
• Anticoagulation alone is appropriate for less severe intermediate-risk presentations 2
• Assess for ECG abnormalities indicating right-heart strain (ST/T changes, S1Q3T3, RV hypertrophy criteria) 1

Low-Risk PE (Hemodynamically Stable)

Anticoagulation is the mainstay of therapy for hemodynamically stable children 4

Standard anticoagulation approach:

• Duration typically ranges from 3-6 months, though optimal duration remains uncertain and may differ from the standard 3-month adult approach 1
• Heparin followed by transition to oral anticoagulation follows adult protocols, as pediatric-specific trials are lacking 4

Critical Caveats and Institutional Considerations

Standardized Protocols

• Institutions should develop standardized protocols for pediatric PE management, with explicit documentation when variations occur 1
• PE response teams may streamline care during these critical events 2

Common Pitfalls

• Avoid delayed diagnosis by recognizing that clinical presentation is often subtle or masked by underlying conditions 4
• Do not rely solely on adult prediction models (Wells, PERC) without understanding their limitations in pediatric populations 3
• Consider incidental/subclinical PE found on imaging for other indications; optimal management of these cases requires individualized assessment 1

Special Populations

• Central venous line-associated PE is particularly common and should be suspected in any child with CVL and respiratory symptoms 1
• Distinguish thromboembolic PE from in-situ pulmonary artery thrombosis (ISPAT) in children with congenital heart disease or pulmonary artery anomalies 1

Long-Term Monitoring

• Monitor for chronic thromboembolic pulmonary hypertension (CTEPH), exercise capacity, and quality of life, as long-term outcomes remain poorly characterized 1
• Thrombophilia testing may be considered but has variable utility in predicting outcomes 1