Emergency Department, ICU, and Inpatient Clinical Pathway
for Children with Suspected Acute Pulmonary Embolism

Goal and Metrics
Provider Resources
Child with suspected pulmonary embolism (PE)
Exclusions: Child in the CCU, CPRU and CICU
  • Transfer from Outside Hospital
    • Recommend OSH images are uploaded.
    • Medical command/PICU consults Hematology for initial anticoagulation recommendations for acute PE.
 
 

History and Physical Exam

Review Risk Factors for PE

 
 
 
 
Hemodynamically Unstable
Perform Diagnostic evaluation as able
 
 
Recommended Antecubital
IV Sizes for CTA
Weight IV size
< 10 kg 24 g
10-30 kg 22 g
30-40 kg 20 g power injector tubing necessary
> 40 kg 18 g clave only
Direct any questions to CT tech at
PHL campus x57020
Diagnostic Evaluation
  • Laboratory
    • CBC, CMP
    • Troponin, BNP
    • D-dimer, PT/INR, PTT, fibrinogen
    • Type and screen
    • VBG or ABG with lactate
  • ECG
  • CTA PE protocol, IV catheter size
 
 
Assess for other causes
 
 
CTA with no PE
CTA with PE
Initiate anticoagulation
with Hematology Consult
Enoxaparin vs. Unfractionated Heparin (UFH)
 
 
Evaluate for right heart dysfunction
Echo Protocol
Focused Pulmonary Hypertension Protocol + RV/LV
  • All the following:
    • CTA: no RV dilation and small clot burden
    • BNP and normal troponin
  • ≥ 1 of the following:
    • Sustained tachycardia
    • Supplemental oxygen requirement
    • CTA: RV dilation, large clot burden
    • BNP > 100 or troponin > ULN
  • Cardiac arrest
  • Shock
  • Sustained hypotension
Echo within 24 Hours
Urgent Echo (< 6 Hours)
Immediate Echo
 
 
 
 
 
 
Pulmonary Embolism Risk Stratification with Hematology or PERT Consultation
 
 
Low Risk PE
  • Clinical, Diagnostic Criteria
    • Normotensive
    • CTA: no RV dilation
    • BNP < 100 pg/mL
    • Troponin < ULN
    • Normal echo
  • Disposition
    • Inpatient unit
  • LE US Doppler
Decompensation
Intermediate Risk PE
  • Clinical, Diagnostic Criteria
  • Consult
    • Hematology who will activate PERT
    • Cardiology consult team
  • Treatment
    • Anticoagulation w/enoxaparin or UFH
    • Consider systemic or catheter directed tPA if no contraindications
  • Disposition
    • PICU
    • A subset may be eligible for inpatient care after Hematology consultation
  • LE US Doppler when stable
Decompensation
High Risk PE
  • Clinical, Diagnostic Criteria
    • Cardiac arrest
    • Sustained hypotension or shock
  • Consult
    • PICU/Hematology, who will activate PERT
    • Cardiology consult team
  • Treatment
    • Consider systemic or catheter directed tPA if no contraindications
    • +/- anticoagulation w/UFH
  • Consider Additional Interventions
    • VA-ECMO
    • Surgical thrombectomy
  • Disposition
    • PICU
Posted: September 2022
Revised: October 2023
Editors: Clinical Pathways Team