Pediatric emergency medicine trisk 2800 2800

Dyspnea, pleuritic chest pain, cough, and occasionally hemoptysis are the most common symptoms of PE in both adults and children, however children with these symptoms are more likely to have alternative diagnoses Less frequent symptoms such as apprehension, fever, sweats, and palpitations are similarly nonspecific Signs and symptoms attributable to concurrent deep venous thrombosis may also be present Current literature in adults suggests that 25% of patients with PE will be asymptomatic which further complicates recognition The presence of asymptomatic disease in children has not been similarly reported, however this may reflect different methodologies in available registries and studies which have not screened for subclinical disease in pediatric populations Abnormal physical examination findings are often absent Tachycardia, rales, and tachypnea are the most common signs in children, though each individual finding is nonspecific Significant vascular obstruction that results in pulmonary hypertension and cardiovascular dysfunction may lead to distended neck veins, a prominent S2 , or a ventricular gallop, although these findings may be seen only with significant cardiopulmonary compromise Similarly, in cases where embolism results in large pulmonary infarction, there may be decreased resonance over the lung fields, crackles, or a pleural friction rub The presence of tachycardia or hypoxemia not clearly explained by an underlying disease process or clinical state should also raise concern for possible PE Management As mentioned above, the challenge is rapidly identifying the minority of patients with PE from other children who present with similar nonspecific complaints and findings, while minimizing unnecessary, higher risk, and invasive testing To supplement initial assessment based on history, physical examination, and review of possible risk factors, some diagnostic studies may help inform the likelihood of PE Once diagnosed, treatment involves supportive care, and prevention of thrombus progression and recurrence An EKG should be obtained, though, as with history and examination findings, abnormalities are rare and nonspecific when present ( Table 99.7 ) Sinus tachycardia is the most common EKG finding, but least specific Conversely, right axis deviation, new complete right bundle branch block, T-wave inversion in leads V1 -V4 , dominant R-wave in V1 , right atrial enlargement, and the classic “S1 , Q3 , T3 ” are all consistent with cor pulmonale which is seen in significantly symptomatic patients with PE, but may also be seen in nonembolic disease including pneumothorax