CLINICAL CRITERIA FOR IMAGING CHILDREN AT RISK FOR PULMONARY EMBOLISM.

CLINICAL CRITERIA FOR IMAGING CHILDREN AT RISK FOR PULMONARY EMBOLISM. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 26 May 2025 V1 Latest version Share on CLINICAL CRITERIA FOR IMAGING CHILDREN AT RISK FOR PULMONARY EMBOLISM. Authors : Pulin B. Koul , Issa Hanna 0000-0002-7259-4587 [email protected] , and Amy Crisp Authors Info & Affiliations https://doi.org/10.22541/au.174828087.70870960/v1 313 views 93 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction : Pulmonary embolism (PE) is a rare, but serious condition in children. Clinical Guidelines for imaging a suspected pediatric PE, in Pediatric Emergency Medicine [PEM] are lacking. The computerized Tomography Pulmonary Angiogram (CTPA) is the preferred diagnostic modality for suspected PE in an emergency room. Our study aims to introduce a simplified clinical assessment-based tool for ordering CTPA in children in an emergency room setting. Methods : This is a retrospective review of patients managed in our Emergency Department from 2000 to 2020. Patients were identified based on the International Classification of Disease codes related to PE, deep vein thrombosis, or similar diagnoses. The control group was patients with symptoms of PE, seen in the same time frame as the study group, who had negative CTPA. Results : Twenty-five CTPA-positive patients were identified. Twenty three of 25 CTPA positive patients were between 13 to 18 years old. Common risk factors included here are protein-losing state i.e. nephrotic syndrome. Others include oral contraceptive pill use, and obesity. Chest pain and tachypnea were the most common complaint and clinical sign, respectively. Hypercoagulability screen was negative in 65% of the patients. The mean D-dimer was 5.27 g/ml, and 6 patients—of whom 4 had saddle PE—had D-dimer > 10. Reoccurrence of PE and neuro-deficits was noted in 2 patients each. Conclusion : We present clinical criteria for ordering CTPA in children with suspected PE, based on data from our center, and a literature review of pediatric studies. Further multicentric studies, with larger samples, are needed to validate our suggested criteria. not-yet-known not-yet-known not-yet-known unknown CLINICAL CRITERIA FOR IMAGING CHILDREN AT RISK FOR PULMONARY EMBOLISM. Pulin B. Koul MB, MD*, Issa Hanna MD **, Amy Crisp PhD*** * Department of Pediatric Emergency Medicine, Wolfson Children’s Hospital, Jacksonville, Florida **Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida ***Center for Data Solutions, University of Florida College of Medicine Jacksonville, Jacksonville, Florida Corresponding author: Issa Hanna, [email protected] Address: 655 West 8th Street, Jacksonville, Florida 32209 Cell # (904) 704-9192 Fax# (904) 244-5848 Declarations of interest from all authors: none Abstract: Introduction : Pulmonary embolism (PE) is a rare, but serious condition in children. Clinical Guidelines for imaging a suspected pediatric PE, in Pediatric Emergency Medicine [PEM] are lacking. The computerized Tomography Pulmonary Angiogram (CTPA) is the preferred diagnostic modality for suspected PE in an emergency room. Our study aims to introduce a simplified clinical assessment-based tool for ordering CTPA in children in an emergency room setting. Methods : This is a retrospective review of patients managed in our Emergency Department from 2000 to 2020. Patients were identified based on the International Classification of Disease codes related to PE, deep vein thrombosis, or similar diagnoses. The control group was patients with symptoms of PE, seen in the same time frame as the study group, who had negative CTPA. Results : Twenty-five CTPA-positive patients were identified. Twenty three of 25 CTPA positive patients were between 13 to 18 years old. Common risk factors included here are protein-losing state i.e. nephrotic syndrome. Others include oral contraceptive pill use, and obesity. Chest pain and tachypnea were the most common complaint and clinical sign, respectively. Hypercoagulability screen was negative in 65% of the patients. The mean D-dimer was 5.27 g/ml, and 6 patients—of whom 4 had saddle PE—had D-dimer > 10. Reoccurrence of PE and neuro-deficits was noted in 2 patients each. Conclusion : We present clinical criteria for ordering CTPA in children with suspected PE, based on data from our center, and a literature review of pediatric studies. Further multicentric studies, with larger samples, are needed to validate our suggested criteria. INTRODUCTION Loschner first described pulmonary Embolism (PE), a potentially fatal entity in 18611. The accurate incidence of PE in children is unknown; studies report PE incidents range between 0.86 per 10,000 hospital admissions2 or 0.14-0.9 per 100,000 children, with a mortality of 8.9% and a reoccurrence rate of 12.5%3,4. The clinical presentation of PE is protean, and may mimic other conditions, making the diagnosis of PE in children challenging5. PE diagnosis is made at an average of 7 days [range 1-21 days] after the onset of symptoms; it can be asymptomatic in up to 16% of cases6. The utility of adult-based algorithms for the management of PE in children is of limited value7. The central physiological consequence of PE is an increase in alveolar dead space with V/Q mismatch1,4. Classic findings in PE include decreased PaCO2 due to hyperventilation with an increase in the alveolar-arterial (A-a) gradient. PE can be associated with a normal PaCO2 and/or a normal A-a gradient in pediatric patients. Hypotension may be the sequelae of severe acute right ventricular hemodynamic compromise. Right ventricle dilates to accommodate increased afterload with high pressures. This may lead to right coronary artery compression and cardiac ischemia. In addition, the bowing of the intraventricular septum may compromise left ventricular filling and cause decreased cardiac output. Hypoxemia is multifactorial in origin; it may result from atelectasis, infarcted lung parenchyma, reflex broncho-constriction, and, if patent, then shunting of blood through the patent foramen ovale. The significant hemodynamic consequence of PE is a mechanical reduction in the cross-sectional area of the pulmonary vascular bed8,9. Clinically, children with PE, present with dyspnea, pleuritic chest pain, persistent tachypnea, and hypoxemia. Symptoms are evident when approximately 65% of the pulmonary vascular bed is occluded; death ensues after 85% occlusion9,10. Clinical presentation may include, unexplained persistent tachycardia &/or tachypnea, lung crackles, a prominent pulmonic component of the second heart sound, cough, and occasionally hemoptysis 11,12,13. Primary Objective: Computerized Tomography Pulmonary Angiogram (CTPA) of the chest is the definitive modality for choice in the Pediatric Emergency Department for suspected PE. Concern for unnecessary radiation exposure to the pediatric population remains high. Our study aims to introduce a simplified clinical assessment-based tool, for ordering confirmatory imaging in the pediatric emergency department. Secondary Objective: To identify risk factors, and emergent management of patients (1 through 18 years) with confirmed pulmonary embolism. To find if any cut-off value of D-dimer is useful as a screening tool, in suspected high-probability PE patients. MATERIALS AND METHODS Setting: A single-center, retrospective chart review analysis of pediatric patients (1 to 18 years) from a tertiary care children hospital, with a confirmed CTPA diagnosis of PE. Study design and data collection: The Baptist Health Institutional Review Board (IRB) approved the study and granted an exemption from full IRB review and informed consent, as it is a retrospective analysis of existing data and poses minimal risk. Patients’ electronic medical records, presenting from January 2000 to January 2020, were analyzed. International Classification of Disease, 9th and 10th (ICD-9, ICD-10) revision coded for PE, Deep Vein Thrombosis (DVT), or similar diagnosis was used to identify the patients. Electronic medical records of all the patients who met the inclusion criteria were included in the study [see figure 1]. After masking patient identifiers, data was extracted in a standardized manner, on premade proforma, independently by authors, and later reconciled. Demographic data included age, gender, and race. Risk factors recorded included obesity, DVT, malignancy, recent surgery or immobilization, and prolonged use of oral contraceptive pills (OCP). A history of shortness of breath, chest pain, fainting episodes, smoking, hemoptysis, and extremity pain/swelling recorded. Family history of PE was noted, including any specific hematologic diagnosis. Initial signs of tachycardia [> 95 centiles for age], tachypnea [> 95 centiles for age], hypoxia [SpO2 < 92%]; chest pain, and extremity pain/swelling were noted. Initial D-dimer and repeat levels, if documented, were recorded. CTPA findings were recorded for the site of occurrence [central pulmonary circulation vs. peripheral, bilateral/unilateral or sub-segmental]. Therapeutic management of PE during hospital stay, including complications and sequelae, and long-term follow-up were noted. Missing historical data was considered negative if not recorded. RESULTS Data analysis: Descriptive statistics are included as counts and percentages. Comparisons of demographic characteristics and variables were performed using t-tests for continuous variables and Fisher’s exact tests for categorical variables. There were no significant differences in demographics between the CTPA positive and negative groups [table 1]. The sensitivity and specificity of the proposed algorithm were calculated by implementing the algorithm for the available pediatric patient data, and then comparing the algorithm results with the known actual outcomes. Area Under the Curve (AUC) and its 95% confidence interval, were computed using the pROC package in R14. We identified 25 CTPA-positive patients during the study period [see figure 1]. The control group consisted of patients with symptoms of PE seen in the same time frame as the control group that had negative CTPA. Clinical symptoms between CTPA groups were performed using Fisher’s Exact test for categorical variables and a t-test for continuous ones. STRATIFICATION: According to American Heart Association (AHA) guidelines15, six patients had massive PE with Hypotension [SBP< 5 centile for age], pulselessness, or severe bradycardia (6 patients), and 19 patients had sub-massive: hemodynamically stable with RV strain. As shown in table 2, initial D-dimer was obtained in 23 patients of 25 in the CTPA-positive group, with a mean of 5.27 g/ml (SD of 5.19) compared to a mean of 0.977 g/ml (SD of 0.905) in the CTPA-negative group with a p-value 20 g/ml. PROTHROMBOTIC PANEL RESULTS: Coagulopathy studies were done in 23 patients out of 25; only 8 patients (one-third) had positive workup, 4 of these had protein deficiency (C,S, or antithrombin III), 2 patients had positive Lupus antibodies, one patient was heterozygous for Factor V Leiden, and one patient had saddle emboli with increased levels of plasminogen activator inhibitor type 1 (PAI 1). DISCUSSION PE is a high-risk, potentially fatal entity; a quick and definitive diagnosis is therefore imperative16. A high index of clinical suspicion is fundamental for the diagnosis of PE. Concern for unnecessary radiation remains a significant risk in the pediatric population for lifelong malignancies. Among the 25 CTPA-positive patients, common risk factors identified in our study include a protein-losing state, specifically, steroid-resistant Nephrotic Syndrome1,5. OCP and obesity were other risk factors, in consonance with other reported studies6,17. PE may be in fact, underreported 1. Single-center autopsy results in the prethrombolytic era determined incidence to be 3.7%18. In all our patients, the diagnosis was confirmed within the first 24 hours, similar to previous observations 1. Unlike prior studies 1,8, in our study, we had 23 of 25 CTPA positive patients between 13 to 18 years old. PE appears to be a predominant condition in adolescents, also noted in a recent study by Sharaf et al2. In our study, there was no clear predominance of any one ethnicity or gender. Obesity was seen in 16 of 25 patients with PE, which was significantly different from the CTPA-negative group [p-value 0.016]. Oral contraceptive use is a known risk factor for PE. It is thought to occur as a result of resistance to third-generation birth control Norgestimate to endogenous anticoagulant activated protein C17. Seven of our patients were on OCP when they developed PE, and four of them had more than one risk factor. The most common presenting complaint in our study was chest pain, 18 of 25 [72%], comparable to what has been previously reported10,11,12. PE can occur in the absence of hypoxemia, with normal alveolar-arterial oxygen gradient in the presence of medication-induced cyclooxygenase inhibition13 as was seen in 6 (24%) of our patients. Leg swelling was a presenting symptom in 6 cases, with shortness of breath and shock in 5 cases. Tachypnea was the most common clinical sign. Other presentations included hemoptysis, syncope, SVC syndrome, and high fever with abdominal pain. Immobility, as a risk factor related to home confinement after surgery, was seen in 3 of our patients. Clinical use of capnography, with increased end-tidal CO2 [ETCO2] reflecting the alveolar dead space above 40 mmHg, is a useful bedside indicator19. In conjunction with high d-Dimer, it increases the suspicion for PE with a sensitivity of 89.7%20. Losses of coagulant proteins like AT III, low functional levels of Protein C & S, and the presence of Lupus anticoagulant21 are known risk factors for Prothrombotic activity. Decreased Profibrinolysin, increased levels of factors V, VII, vW factor and increased lipoprotein A, increasing platelet aggregation and attachment and release of α –granules, with the use of steroids and diuretics, may contribute to the increased propensity of PE in Nephrotic Syndrome (NS). Furthermore, it has been suggested that abnormal rheological properties of red blood cells may contribute to the tendency of thrombosis in nephrotic patients22. The reported incidence of thrombi developing in patients on steroids, and diuretics was 5-10%21,22. A recent study determined that thromboembolic events could happen in about 5% of children with steroids-resistant NS, especially in the first three months after the diagnosis22 . In a retrospective study of 622 children with NS by Boussetta et al., 19 of them developed thromboembolic events. D-dimer was elevated in the 5 cases; left pulmonary artery embolism was identified in the 5 cases, 3 of whom died due to PE, and respiratory failure 23. In our cohort, we also noted one patient with severe chronic Inflammatory Bowel Disease (IBD) who developed PE. Prothrombotic proclivity in this subset of patients may be due to decreased levels of Protein C, increased levels of Factor I & VIII & accelerated thromboplastin generation. Based on analysis of our data, and literature review, we propose the clinical criteria [table 3] for using CTPA only in high-probability cases, to limit radiation exposure. In our study, these criteria had a sensitivity of 76% and specificity of 92.9%. Lee EY et al. based on CTPA confirmed 36 cases, recommended using two or more risk factors as the clinical threshold for obtaining diagnostic scans. These included immobilization, hypercoagulable state, central venous catheter, OCP use, or prior DVT/PE 24. In our study, we excluded patients with catheter in situ to eliminate preexisting known risk factor for thrombus formation. In our series, in the control group, 27 patients had chest pain but had negative CTPA, exposing them to unnecessary radiation, which is of concern. Van Belle et al. using two or more risk factors, the diagnostic scan yielded a sensitivity of 86% and a specificity of 94%25. This is similar to our results. Our clinical assessment tool for ordering CTPA, relies exclusively on history and exam. Point of Care Ultrasound (POCUS) cardiac should be performed in ED for all suspected PE patients, as was done in all our acute massive PE patients, to evaluate right heart contractility and Inferior Vena Cava (IVC) volume. It is a valuable adjunct in patients presenting as Acute Corpulmonale 26. Echocardiography, another adjunct, may provide information about abnormal hemodynamics. It may guide clinicians to opt for surgical embolectomy or ECMO, as happened in one of our patients with acute massive PE. In our study, clot burden was seen in both lungs [figure 3], similar to the study by Lucas et al7. A review of the literature for pediatric massive severe PE revealed twenty reports 27. The reported age range was 10-19 years, with a mortality of 38%. The presentation was Acute Corpulmonale features with severe tachypnea and tachycardia and features of RV stain pattern on EKG. In this series, out of six with massive PE, four presented with Acute Corpulmonale. The role of cardiac troponin in pediatric PE is unknown; however, it may be high in Acute Corpulmonale, as was seen in our patients with massive PE. There was, however, no death in our cohort. One patient had a saddle thrombus, presenting in shock that needed prolonged CPR with ECMO salvage. D-dimer is a marker for fibrin turnover and thrombotic and thrombolytic activity. Its use as a decision-making tool in deciding to order CTPA, in the pediatric population is not well elucidated. The data on D-dimer cut-off levels in pediatric PE is not as compelling, except for early adolescent data2. There is an incongruity in the literature about using D-dimer alone and as part of Wells criteria, and Pulmonary Embolism Rule-Out Criteria (PERC) rule as applied to the pediatric age group. Sharaf et al. suggest a 0.75 g/ml cut-off in adolescent patients2. Its application as a screening tool in the pediatric population revealed it to be normal in 15 to 40% of patients6. False negative may result from the small size of the embolus or PE > 3 days, while false positive levels may be seen in malignancy, recent surgery, or infection5. In our series, a quantitative mean of the D-dimer level of 5.27 g/ml was seen in 92% of our patients. Only in five patients, of whom 4 were African Americans, had saddle or extensive thrombus was D- dimer In a study by Kanis et al., D-dimer was ordered in 88% of children positive- patients had a mean D-dimer value of 2.104 g/ml (SD of 1.394) with a sensitivity of 100% and a low specificity of 58% 28. A study by Brangaca et al., using PERC, identified all symptomatic PE, the only study to endorse this criterion29. It is pertinent to note that there were no outpatient oncologic cases in the study. Lee et al and Hennelly et al found that PERC rule, had sensitivity and specificity at 69% & 85% and 100% and 24 % respectively29,30 . In contrast, 3 patents were missed in the former, one in the latter. The sequelae were seen in 5 of 25 patients. The reoccurrence of PE was noted in 2, and neuro-deficits in 2, with one patient developing NS. Compression duplex ultrasound of the lower extremity is an essential adjunct to diagnosing PE and should be done in all patients where clinical suspicion of PE is high. In our series, only two patients presented with leg pain; however, six patients had lower extremity clots. In one of the large PE pediatric registries, two-thirds of DVT were reported to occur in the upper extremities as opposed to lower extremities as seen in adults4. Many congenital coagulation abnormalities may be present in adolescents, such as factor V Leiden, Prothrombin G20210A mutations, Hyper-Homocysteinemia, Protein C and S deficiency, and increase the level of lipoprotein A29,30. The hypercoagulability screen in our cohort was negative in 15 of 23 patients (65%). Reports in the literature, vary between 13 to 78.6%4. All patients should, at the appropriate time, have a hypercoagulability screen done. The goal of management is to use diagnostics efficiently, resuscitate, if need be, and start treatment in the ED itself. Attention to basic principles of resuscitation is imperative. Formation of Pulmonary Embolism Response Team (PERT) is imperative in every tertiary care facility. Immediate consultation with the Critical Care team for possible VA ECMO is essential. Time permitting consults with cardiologist for echocardiogram, and hematologist is imperative. In patients with saddle thrombi, one may need support from anesthesia & CV Surgeon for thrombectomy, as happened in one of our patients, who presented with Acute Corpulmonale. Both unfractionated Heparin and Low Molecular Weight Heparin [LMWH] have been used for management of PE. Heparin infusion should be started in the ED itself after the diagnosis is confirmed. REFERNCES 1) Biss, T.T., Brandão, L.R., Kahr, W.H., Chan, A.K. and Williams, S., 2008. Clinical features and outcome of pulmonary embolism in children. 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BMC bioinformatics, 12(1), 1-8.) 15) Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, Piazza G, Gladwin MT, Chatterjee S, Kobayashi T, Kabrhel C, Barnes GD. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation. 2019 Nov 12;140(20):e774-e801. doi: 16) Rajpurkar M, Warrier I, Chitlur M, Sabo C, Frey MJ, Hollon W, Lusher J. Pulmonary embolism-experience at a single children’s hospital. Thromb Res. 17) Rosing J, Middeldorp S, Curvers J, Christella M, Thomassen LG, Nicolaes GA, Meijers JC, Bouma BN, Büller HR, Prins MH, Tans G. Low-dose oral contraceptives and acquired resistance to activated protein C: a randomised cross-over study. Lancet. 1999 Dec 11;354(9195):2036-40. doi: 10.1016/s0140-6736(99)06092-4. PMID: 10636369 18) Morgenthaler TI, Ryu JH. Clinical characteristics of fatal pulmonary embolism in a referral hospital. Mayo Clin Proc. 1995 May;70(5):417-24. doi: 10.4065/70.5.417. PMID: 7731250. 19) Manara A, D’hoore W, Thys F. Capnography as a diagnostic tool for pulmonary embolism: a meta-analysis. Ann Emerg Med. 2013 Dec;62(6):584-91. doi: 10.1016/j.annemergmed.2013.04.010. Epub 2013 Jun 12. PMID: 23769645. 20) Bello N, Meyers KJ, Workman J, Marcano Belisario J, Cervera R. Systematic Literature Review and Meta-analysis of Venous Thromboembolism Events in Systemic Lupus Erythematosus. Rheumatol Ther. 2023 Feb;10(1):7-34. doi: 10.1007/s40744-022-00513-1. Epub 2022 Dec 6. PMID: 36471199; PMCID: PMC9931974. 21) Zhu H, Qi J, Schoepf J, Savage RH, Tang C, Lu M, Zhou C, Lu G, Wang D, Zhang L. Prevalence and Associated Risk Factors of Pulmonary Embolism in Children and Young Adults With Nephrotic Syndrome: A Chinese Large Cohort Study. J Thorac Imaging. 2021 Sep 1;36(5):326-332. doi: 10.1097/RTI.0000000000000603. PMID: 34269751. 22) Torres RA, Torres BR, Castilho AS, Honorato R. Venous sinus thrombosis in a child with nephrotic syndrome: a case report and literature review. Rev Bras Ter Intensiva. 2014;26(4):430–434 23) Boussetta A, Jaber C, Jellouli M, Gargah T. Thromboembolic complications in children with primary nephrotic syndrome: A Tunisian series. Tunis Med. 2022 Janvier;100(1):33-36. PMID: 35822329; PMCID: PMC8996312. 24) Lee EY, Tse SK, Zurakowski D, Johnson VM, Lee NJ, Tracy DA, Boiselle PM. Children suspected of having pulmonary embolism: multidetector CT pulmonary angiography–thromboembolic risk factors and implications for appropriate use. Radiology. 2012 Jan;262(1):242-51. doi: 10.1148/radiol.11111056. Epub 2011 Nov 21. PMID: 22106353. 25) Van Belle, A., Büller, H.R., Huisman, M.V., Huisman, P.M., Kaasjager, K., Kamphuisen, P.W., Kramer, M.H., Kruip, M.J., Kwakkel-van Erp, J.M., Leebeek, F.W. and Nijkeuter, M., 2006. Christopher Study Investigators: Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA, 295(2), pp.172-179. 26) Kagima J, Stolbrink M, Masheti S, Mbaiyani C, Munubi A, Joekes E, Mortimer K, Rylance J, Morton B. Diagnostic accuracy of combined thoracic and cardiac sonography for the diagnosis of pulmonary embolism: A systematic review and meta-analysis. PLoS One. 2020 Sep 28;15(9):e0235940. doi: 10.1371/journal.pone.0235940. PMID: 32986723; PMCID: PMC7521742. 27) Killinger, J.S., Baird, J.S., Bye, M.R. and Schleien, C.L., 2005. ANATOMIC MASSIVE PULMONARY EMBOLISM (AMPE) IN CHILDREN.: 275-T. Critical Care Medicine, 33(12), p.A182. 28) Kanis J, Hall CL, Pike J, Kline JA. Diagnostic accuracy of the D-dimer in children. Arch Dis Child. 2018 Sep;103(9):832-834. doi: 10.1136/archdischild-2017-313315. Epub 2017 Nov 8. PMID: 29117965. 29) Lopes de Braganca, R., Gorito, V., Cibele, D. G., Ricca Goncalves, L., Ribeiro, A., Baptista, M. J., & Azevedo, I. (2021). Pulmonary embolism in pediatric age: A retrospective study from a tertiary center. Pediatric Pulmonology, 56(8), 2751-2760. 30) Hennelly, K. E., Baskin, M. N., Monuteuax, M. C., Hudgins, J., Kua, E., Commeree, A., … & Neuman, M. I. (2016). Detection of pulmonary embolism in high-risk children. The Journal of Pediatrics, 178, 214-218. Untitled Document Generated on Mon May 26 08:25:17 2025 by LaTeXML & & Figure 1. FLOW DIAGRAM FOR DATA COLLECTION The Flowchart demonstrates the study sample’s identification, inclusion, and exclusion with the number of patients in parentheses. Figure 2. Initial D-dimer values. Figure 3. Illustration of the site of emboli as shown in the CTPA in our cohort. Right Lung (RL), Left Lung (LL), Right Upper Lung (RUL), Right Middle Lobe (RML), Right Lower Lobe (RLL), Right Pulmonary Artery (RPA), Left Pulmonary Artery (LPA), Left Lower Lobe (LLL), Inferior Vena Cava (IVC) Table1. Demographics and Clinical Symptoms Age (Years) Mean [SD] 15.6 (2.44) 15.0 (2.64) 16.1 (2.17) 0.101 Gender 1 Female 32 (60.4%) 15 (60.0%) 17 (60.7%) Male 21 (39.6%) 10 (40.0%) 11 (39.3%) Race 0.87 Caucasian 27 (50.9%) 12 (48.0%) 15 (53.6%) African American 25 (47.2%) 12 (48.0%) 13 (46.4%) Asian 1 (1.9%) 1 (4.0%) 0 (0%) Chest Pain 18 (72%) 27 (96.4%) 0.0199 Shortness of Breath (SOB) 18 (72%) 13 (46.4%) 0.0937 Hypoxia 19 (76%) 4 (14.3%) <0.001 Tachycardia 19 (76%) 13 (46.4%) 0.0481 Leg Swelling 12 (48%) 0 (0%) <0.001 Protein-Losing State 9 (36%) 0 (0%) <0.001 Table2. INITIAL D-DIMER LEVEL ANALYSIS(g/ml): Mean [SD] 3.27 [4.38] 5.27 [5.19] 0.977 [0.905] <0.001 Median [Min, Max] 1.95 [0.150, 20.0] 3.06 [0.640, 20.0] 0.805 [0.150, 3.98] Missing 2 [8.0%] 8 [28.6%] * p-value is from a t-test. Table 3. SUGGESTED CRITERIA FOR SUSPECTING & ORDERING CTPA Need Two Major; One Major+ 2 Minor or > 2 minor to order CTPA. Protein Losing State [N.S; I.B.D] BMI>95centile for age Chest Pain/SOB with SpO 2 40 mmHg Prolonged OCP use MINOR Recent or current oncologic diagnosis PMH of PE or DVT or current leg swelling FH of Coagulopathy/Hypercoagulable state Unexplained persistent tachycardia Prolonged Immobilization Information & Authors Information Version history V1 Version 1 26 May 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords adolescents computerized tomographic pulmonary angiogram (ctpa) crinical criteria pediatric emergency medicine (pem) pulmonary embolism (pe) Authors Affiliations Pulin B. Koul Wolfson Children's Hospital View all articles by this author Issa Hanna 0000-0002-7259-4587 [email protected] University Florida Department of Emergency Medicine - Jacksonville View all articles by this author Amy Crisp University of Florida College of Medicine - Jacksonville View all articles by this author Metrics & Citations Metrics Article Usage 313 views 93 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Pulin B. Koul, Issa Hanna, Amy Crisp. CLINICAL CRITERIA FOR IMAGING CHILDREN AT RISK FOR PULMONARY EMBOLISM.. Authorea . 26 May 2025. DOI: https://doi.org/10.22541/au.174828087.70870960/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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