Identification and Management of Pediatric Venous Thromboembolism in the Emergency Department

Publication Date: May 2024 (Volume 21, Number 5)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 05/01/2027.

Authors

Michael P. Johnson, MD

Pediatric Emergency Medicine Fellow, University of Rochester Medical Center, Rochester, NY

Asim A. Abbasi, MD, MPH

Assistant Professor of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY

Peer Reviewers

Nicole Gerber, MD

Assistant Professor of Clinical Emergency Medicine and Pediatrics, New York Presbyterian/Weill Cornell Medicine, New York, NY

Tim Horeczko, MD, MSCR, FACEP, FAAP

Professor of Clinical Emergency Medicine, David Geffen School of Medicine, UCLA; Director of Pediatric Emergency Medicine Fellowship, Los Angeles County Harbor-UCLA Medial Center, Torrence, CA

Abstract

Although the incidence of pediatric venous thromboembolism is increasing, it is often overlooked in children due to the overall low incidence. This issue reviews the epidemiology of pediatric venous thromboembolism, including the factors that have led to its increasing prevalence, and discusses the physiology of hemostasis and coagulation. Key features of the history and physical examination, as well as identification of risk factors, are reviewed, as these have the most diagnostic value for venous thromboembolism in pediatric patients. Recommendations are also provided for diagnostic testing and management in the emergency department.

Case Presentations

CASE 1

A 13-year-old girl is brought into the ED after she developed dyspnea and pleuritic chest pain while watching a basketball game...

The girl is tachypneic and mildly tachycardic, with an oxygen saturation of 98% on room air. As you begin the workup, her mother mentions that her daughter underwent pinning of a leg fracture recently and has been immobile for the past 6 days. She says the girl started taking oral contraceptives 3 months ago.
How should you begin your workup? Does this patient require emergent imaging to rule out a pulmonary embolism?

CASE 2

A father brings in his 3-year-old daughter for difficulty using her central venous catheter…

The girl is currently undergoing induction-phase treatment for acute lymphoblastic leukemia. They are accompanied by the home nurse who states that there has been difficulty flushing home medications through the girl’s central venous catheter. The girl has otherwise been doing well, without any fevers or other symptoms.
Your ED team administered a trial of alteplase with no success.
Should you try alteplase again? What other options should be considered for management of this patient?

CASE 3

A 17-year-old girl with autism and intellectual disability is brought in after she was diagnosed with a deep vein thrombosis at her doctor’s office…

Due to miscommunication between her parents, she has been getting her oral contraceptive medication (prescribed for dysmenorrhea) twice a day instead of once a day. She developed leg pain and swelling 3 days ago, and an ultrasound today confirmed a popliteal vein thrombus.
The girl is nonverbal. Her parents do not think she has had any difficulty breathing, and she has normal vital signs in the ED.
Does this patient need to be treated for her deep vein thrombosis? Does she need other imaging or laboratory studies?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.