Acute Pulmonary Embolism Clinical Pathway — Emergency Department, ICU and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goal and Metrics

Provider Resources

Related Pathways
VTE Prevention, Inpatient
Venous Thromboembolism, Catheter-Related, CICU and CCU

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

Hematology consult
Consider empiric tPA if:
- Arrest with known PE
- No tPA contraindications

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

Consult
- Hematology
Treatment
- Enoxaparin

Disposition
- Inpatient unit

LE US Doppler

Decompensation

Intermediate Risk PE

Clinical, Diagnostic Criteria
- Normotensive
- ≥ 1 of the following:
  - CTA: RV dilation
  - BNP > 100 pg/mL
  - Troponin > ULN
  - Abnormal echo findings

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

Authors:
- L. Raffini, MD;
- H. Whitworth, MD;
- A. Ellison, MD;
- C. Davis, MD;
- A. Himebauch, MD;
- D. Davis, MD;
- C. Ravishankar, MD;
- M. O’Byrne, MD;
- L. Mercer-Rosa, MD;
- C. Avitabile, MD;
- C. Mavroudis, MD;
- B. Blowey, PharmD;
- C. Law, PharmD

Editors: Clinical Pathways Team

Evidence

CHOP Program

Thrombosis Program

Related Links

The PERT Consortium

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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

Evidence

CHOP Program

Related Links

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