Evaluation of the pulmonary embolism rule out criteria (PERC rule) in children evaluated for suspected pulmonary embolism

Kline, Jeffrey A.; Ellison, Angela M.; Kanis, Jessica; Pike, Jonathan; Hall, Cassandra L.

doi:10.1016/j.thromres.2018.05.026

Cited by 8 publications

(19 citation statements)

References 19 publications

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“…While clinical pretest probability tools such as the PE rule out criteria (PERC rule), Wells score, revised Geneva score (RGS), and simplified RGS have been developed to facilitate timely diagnosis of VTE in adults, 21 these tools have consistently shown poor performance and reliability in children with VTE. 18,19,22,23 Pilot work on a pediatric-specific clinical pretest probability tool has been published, for which further development and validation is planned. 23,24 Although D-dimer is used as a screening tool to rule out PE in low-risk adults, it is neither sensitive nor specific for pediatric VTE.…”

Section: Diagnostic Evaluationmentioning

confidence: 99%

Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives

White

Betensky

Lawson

et al. 2021

Semin Thromb Hemost

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Pediatric venous thromboembolism (VTE) is a condition increasingly encountered by emergency medicine physicians. Unfortunately, despite increased incidence, the diagnosis of pediatric VTE relies on a high index of suspicion from clinicians. Delays in diagnosis and initiation of treatment can lead to poor outcomes in children, including an increased risk of mortality from pulmonary embolism, increased risk of VTE recurrence, and the development of the post-thrombotic syndrome. The majority of pediatric VTE events are associated with the presence of at least one underlying prothrombotic risk. Timely recognition of these risk factors in the emergency department (ED) setting is paramount for a prompt diagnosis and treatment initiation. Compared with children with hospital-acquired VTE, children presenting to the ED with new onset VTE tend to be older (>11 years of age), have a lower incidence of co-morbidities, and present more frequently with a deep venous thrombosis of the lower extremity. Currently, there are no validated pediatric-specific VTE clinical pretest probability tools that reliably assist with the accurate and timely diagnosis of pediatric VTE. Compression ultrasound with Doppler is the most common imaging modality used for VTE diagnosis, and low molecular weight heparins are the most common anticoagulants initiated in children presenting with VTE in the ED. Special consideration should be given to patients who present to the ED already on anticoagulation therapy who may require acute management for clinically-significant bleeding or change in antithrombotic therapy approach for progression/recurrence of VTE.

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Section: Diagnostic Evaluationmentioning

confidence: 99%

Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives

White

Betensky

Lawson

et al. 2021

Semin Thromb Hemost

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“…Simplified, revised Geneva score, based on several clinical variables, i.e., hemoptysis, old age of more than 65 years, history of venous thromboembolism, tachycardia, unilateral lower limb pain with or without deep palpation and edema, active malignancy, and surgery or fracture of lower limb within 1 month prior to the suspected symptoms and signs, has been published to use for diagnosing pulmonary thromboembolism. The more scores patients get, the higher chance of pulmonary embolism patients have [28]. Computed tomography pulmonary angiography, magnetic resonance pulmonary angiography, and ventilation/perfusion scan could be used to diagnose pulmonary thromboembolism even though conventional pulmonary angiography is the gold standard [29].…”

Section: Venous Thromboembolismmentioning

confidence: 99%

Thromboembolism in Beta-Thalassemia Disease

Natesirinilkul¹

2020

Beta Thalassemia

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Thalassemia disease is a common inherited hemolytic anemia frequently found in several parts of the world, especially in the Mediterranean and some Asian countries. Besides the complications of secondary hemochromatosis from regular red blood cell (RBC) transfusion and increased gastrointestinal absorption of iron, thromboembolism (TE) is one of the common long-term complications of beta-thalassemia disease, particularly in patients with non-transfusion-dependent thalassemia (NTDT), which is commonly seen after the second decade of life. The risk factors of TE in beta-thalassemia disease including exposure of phosphatidylserine of abnormal RBCs, increase of platelet activation and aggregation, elevation of endothelial microparticles and increased endothelial activation, decreased nitric oxide (NO) secondary to hemolysis, rise of platelet count and nucleated RBCs after splenectomy, organ dysfunction caused by hemochromatosis, and thrombophilia such as natural anticoagulant deficiencies leading to hypercoagulable state. The understanding of the pathophysiology would result in effective prevention of this complication of beta-thalassemia disease.

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“…When applied to 2 independent pediatric cohorts, the PERC rule had a high sensitivity for Hennelly et al (100%) and Kline et al (95.8%). However, specificities were lower, at 24% and 35%, respectively, which limits the usefulness of these rules in clinical practice.…”

Section: Introductionmentioning

confidence: 98%

“…When PE is considered in a differential diagnosis, there is considerable decisional conflict because the clinical presentation of PE overlaps with many common pediatric diseases. The current criterion standard for PE diagnosis is computed tomography pulmonary angiogram (CTPA), but this carries the risk of radiation‐induced malignancy . Balancing the risk of missing a PE against the probable increased risk of a radiation‐induced malignancy presents a clinical conundrum for emergency medicine physicians caring for children.…”

Section: Introductionmentioning

confidence: 99%

Clinical variables that increase the probability of pulmonary embolism diagnosis in symptomatic children

Hennelly

Ellison

Neuman

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. AbstractBackground: Pulmonary embolism (PE) in children carries a significant morbidity and mortality. We examined previously described factors in 2 cohorts of children tested for PE and identified novel factors. Methods:We combined data from 2 retrospective cohorts. Patients up to age 21 years were included who underwent imaging or D-dimer testing for PE, with positive radiologic testing being the gold standard. Combined predictor variables were examined by univariate analysis and then forward stepwise multivariable logistic regression. Results: The combined data set yielded 1103 patients with 42 unique predictor variables, and 93 PE-positive patients (8.4%), with a median age of 16 years. Univariate analysis retained 17 variables, and multivariable logistic regression found 9 significant variables with increased probability of PE diagnosis: age-adjusted tachycardia, tachypnea, hypoxia, unilateral limb swelling, trauma/surgery requiring hospitalization in previous 4 weeks, prior thromboembolism, cancer, anemia, and leukocytosis. Conclusion: This combined data set of children with suspected PE discovered factors that may contribute to a diagnosis of PE: hypoxia, unilateral limb swelling, trauma/ surgery requiring hospitalization in previous 4 weeks, prior thromboembolism, and cancer, age-adjusted tachycardia, tachypnea, anemia, and leukocytosis. Prospective testing is needed to determine which criteria should be used to initiate diagnostic testing for PE in children. Essentials• Pulmonary embolism (PE) in children carries a significant morbidity and mortality.• We combined data from 2 retrospective cohorts and identified novel predictor variables.• Multivariable logistic regression found 9 significant variables associated with PE diagnosis.• Prospective testing is needed to determine which features predict pediatric PE diagnosis.

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Evaluation of the pulmonary embolism rule out criteria (PERC rule) in children evaluated for suspected pulmonary embolism

Abstract: In this sample of children and teenagers with suspected PE, the PERC rule was negative in 31%, and demonstrated good overall diagnostic accuracy, including a low false negative rate. These data support the need for a large, prospective diagnostic validation study of PERC in children.

Cited by 8 publications

References 19 publications

Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives

Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives

Thromboembolism in Beta-Thalassemia Disease

Clinical variables that increase the probability of pulmonary embolism diagnosis in symptomatic children

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