Scoping review of the literature supporting the exclusion of pulmonary embolism without radiation in children.

Introduction: Traditional dogma suggests that acute pulmonary embolism (PE) occurs rarely in children <18 years. However, in the emergency department (ED) setting, the frequency of PE diagnosis in children with signs or symptoms that raise suspicion for PE is unknown. This uncertainty is fueled by the lack of prospective studies of PE exclusion and diagnosis in children. Children occasionally die unexpectedly from an acute PE that was missed during the initial evaluation by a physician. However, over-testing also carries risks.

Areas covered: This review addresses the risks of over-testing and radiation exposure, and the use of clinical criteria to assess the pretest probability of PE to decide when to test for this condition in children. We discuss what is known about the theoretical test threshold and the unstructured and structured pretest probability of PE assessment in children. Additionally, we review the theory behind the D-dimer assay and the current literature that has reported the diagnostic accuracy of the D-dimer for PE in children.

Expert opinion: We propose a hypothetical clinical algorithm that incorporates the use of a prediction rule that relies upon both unstructured and structured pretest probability assessments, coupled with the D-dimer to safely rule out the diagnosis of PE in children without the use of radiation.