Pediatric Pulmonary Embolism: Diagnostic and Management Challenges

Presentation, Management and Outcomes of Pediatric Pulmonary Embolus: A Retrospective Review

OBJECTIVES

To review the presentation, management, and outcomes of pediatric pulmonary embolism (PE) patients treated at a single institution over 10 years to determine whether laboratory findings and clinical presentation predict disease severity.

METHODS

We performed a retrospective chart review of patients treated for PE in a 14-bed pediatric intensive care unit from January 1, 2008, to December 31, 2018. Associations between clot burden and disease severity, clinical risk factors (body mass index, recent hospitalization, estrogen use), clinical presentation (heart rate, oxygen saturation), and laboratory values (white blood cell count, D-Dimer, troponin, proBNP) were performed using Student t test, χ2 tests, and 1-way analysis of variance. Patients were risk stratified by American Heart Association guidelines.

RESULTS

Eighteen (72%) patients (girls) were treated for PE. Common risk factors included recent hospitalization (67%) and oral contraceptives (62%). Risk factors, clinical presentation (including hypoxemia and tachypnea), and laboratory studies did not correlate with disease severity or clot burden. Electrocardiogram and radiographic findings were non-specific. Computer tomography pulmonary angiography (CTPA) was required to diagnose 94%. Sixteen received unfractionated heparin, and 5 required additional intervention. Risk factors, clinical features, and laboratory studies did not predict who required intervention.

CONCLUSIONS

Of 18 pediatric patients treated for PE at a single institution over 10 years, vital signs and laboratory data did not predict disease severity or clot burden, and CTPA was required for diagnosis in all but 1. Emergency room providers must have a high index of suspicion for diagnosis and cannot be reassured by normal electrocardiogram or plain film findings. At a time when pediatric providers are under pressure to minimize unnecessary radiation exposure, this lack of correlation of clinical presentation and laboratory findings highlights the importance of considering CTPA when PE is suspected.

Management of Submassive Bilateral Pulmonary Embolism in an Adolescent Female

Pulmonary embolism (PE) is a rare presentation in the pediatric population. We report a case of submassive PE in an adolescent female following commencement of a combined oral contraceptive pill (COCP). In the setting of cardiac dysfunction, she received systemic thrombolysis with significant reduction of clot burden and clinical improvement objectively demonstrated shortly thereafter. This case highlights challenges in clinical decision-making regarding surgical or catheter-based interventions versus medical management approaches when addressing life-threatening PE in children. Our case demonstrates that submassive PE in pediatrics can be managed successfully with systemic thrombolysis and therapeutic anticoagulation.

Dehydration as a Rare Cause of Pulmonary Artery Thrombosis in a 2-Week-Old Term Neonate

Pulmonary arterial thrombosis is an extremely rare occurrence in the neonatal population. We describe a 2-week-old female neonate who presented in critical condition with severe cyanosis and dehydration and was found to have a large thrombus in the main branches of the pulmonary arteries. She was successfully treated with surgical embolectomy. Pulmonary arterial thrombosis should always be considered in the differential diagnosis of a dehydrated neonate presenting with severe cyanosis and evidence of pulmonary hypertension.