Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pulmonary Infarction Clinical Presentation

  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Jan 16, 2015
 

History

Classic symptoms of pulmonary embolism (PE) are rarely encountered. The frequency with which the diagnosis is missed in both adults and children is striking. Adding to the clinical dilemmas is the fact that few symptoms are sensitive or specific for pulmonary embolism. In adult series, clinical diagnosis has a sensitivity of 85% but a specificity of 38%, reflecting the vast differential diagnosis found in both adults and children. Symptoms vary according to the severity of the pulmonary embolism and the presence of underlying conditions. Pulmonary emboli of small-to-moderate size are generally asymptomatic.

Respiratory symptoms

Pleuritic chest pain is reported to occur in as many as 84% of children and adults with pulmonary emboli. Its presence suggests that the embolus is located more peripherally and, thus, may be smaller.

Tachypnea and dyspnea are observed in as many as 60% of adult patients with pulmonary emboli but are generally less frequent in children.

Cough is present in approximately 50% of children with pulmonary emboli. Hemoptysis is a feature in a minority of children with pulmonary emboli, occurring in about 30% of cases.

Other symptoms

A feeling of apprehension is a manifestation of arousal of the sympathetic system. Sweating and syncope are rarely present.

Risk factors to elicit on history taking

Obtain a detailed history of any previous pulmonary embolism/thromboembolism, oral contraceptive use, recent pregnancy, termination of pregnancy, drug history, and family history.

Sickle cell disease

Patients with sickle cell disease may present with manifestations of sickle cell anemia other than acute chest syndrome. These may include anemia, sequestration crisis, pain crisis, stroke, and priapism.

Next

Physical

The use of physical findings as a diagnostic aid in suspected cases of pulmonary embolism brings the same problems as are outlined in History. Many physical findings are typically less marked than they are in adults, presumably because children have greater hemodynamic reserve and, thus, are better able to tolerate the significant hemodynamic and pulmonary changes.

Pulmonary findings include the following:

  • Tachypnea is a feature in almost 50% of children with pulmonary emboli.
  • Crackles are heard in a minority of cases.
  • Cyanosis and hypoxemia are not prominent features of pulmonary embolism. If present, cyanosis suggests a massive embolism leading to a marked V/Q mismatch and systemic hypoxemia. Some case reports have described massive pediatric pulmonary embolism with normal saturation.
  • A pleural rub is often associated with pleuritic chest pain and indicates an embolism in a peripheral location in the pulmonary vasculature.
  • Signs that indicate pulmonary hypertension and right ventricular failure include a loud pulmonary component of the second heart sound, right ventricular lift, distended neck veins, and hypotension. An increase in pulmonary artery pressure is reportedly not evident until at least 60% of the vascular bed has been occluded.

Cardiovascular findings include the following:

  • A gallop rhythm signifies ventricular failure.
  • Peripheral edema is a sign of congestive heart failure.
  • Various heart murmurs may be audible, including a tricuspid regurgitant murmur signifying pulmonary hypertension.

Other signs include the following:

  • Fever is an unusual sign that is nonspecific.
  • Diaphoresis is a manifestation of sympathetic arousal.
  • Signs of other organ involvement in patients with sickle cell disease would be elicited, such as sequestration crisis, priapism, anemia, and stroke.
Previous
Next

Causes

In contrast with adults, most children (98%) diagnosed with pulmonary emboli have an identifiable risk factor or a serious underlying disorder. DVT is associated with a pulmonary embolism in 30-60% of cases. Thrombosis may also arise from intracardiac thrombi or intracerebral sinus thrombosis.

Acquired thrombosis has 3 broad etiological risk factors: (1) a relative stasis of blood flow due to either immobilization or the presence of a nidus on which a thrombus may form, (2) a prothrombogenic tendency (hypercoagulability), and (3) injury to a vascular wall. These 3 factors have been termed the Virchow triad.

The following conditions predispose to some or all of these factors for acquired thrombosis:

  • Central venous catheters: This is one of the most common acquired risk factors for pediatric PE. In 1993, David et al reported that 21% of children with DVT, pulmonary emboli, or both had an indwelling central venous catheter. [1] Additional series report presence of central lines in as many as 36% of patients. [10] A clot may form as a fibrin sleeve that encases the catheter. When the catheter is removed, the fibrin sleeve is often dislodged, releasing a nidus for embolus formation. In another scenario, a thrombus may adhere to the vessel wall adjacent to the catheter.
  • Surgery: Recent surgery and postsurgical immobilization are associated with approximately 15-29% of pulmonary embolism and DVT cases.
  • Heart disease: Thrombi may be associated with dilated cardiomyopathy, a situation in which sluggish blood flow is combined with an enlarged cardiac chamber.
  • Sickle cell disease: This condition often creates a diagnostic difficulty. A chest infection is often the presenting symptom. Hypoxemia, dehydration, and fever lead to intravascular sludging within pulmonary (among others) vasculature. This promotes a vicious cycle, further exacerbating local hypoxemia, ultimately leading to local tissue infarction. This process is further worsened by bone marrow infarction, which may cause release of fat emboli that lodge in the pulmonary circulation. [11]
  • Trauma: Whether the increased risk of pulmonary embolism in trauma patients is independent of the role of immobilization and surgery is unclear. [8]
  • Neoplasm: Pulmonary emboli have been reported to occur in association with solid tumors, leukemias, and lymphomas. This is probably independent of the indwelling catheters often used in such patients. [12]
  • Hyperalimentation: A recent study reported that major thrombosis or pulmonary embolism was present in more than 33% of children treated with long-term hyperalimentation and that pulmonary embolism was the major cause of death in 30% of these children. Fat embolization may exacerbate this clinical picture. [13]
  • Dehydration: Dehydration, especially hyperosmolar dehydration, is typically observed in younger infants with pulmonary emboli.
  • Inherited disorders of coagulation: In 1993, David et al reported that 5-10% of children with venous thromboembolic disease have inherited disorders of coagulation, such as antithrombin III, protein C, or protein S deficiency. [1] In 1997, Nuss et al reported that 70% of children with a diagnosis of pulmonary embolism have antiphospholipid antibodies or coagulation-regulatory protein abnormalities. [14] However, this was a small study in a population with clinically recognized pulmonary emboli; hence, its applicability to the broader pediatric population is uncertain.

Miscellaneous causes

Other causes of pulmonary embolism include the following:

  • Obesity (BMI ≥ 25 kg/m 2)
  • Estrogen use, including oral contraceptives
  • Pregnancy
  • Pregnancy termination
  • Nephrotic syndrome
  • Ventriculoatrial shunt: The tip of the atrial shunt may act as a nidus for thrombus formation.
  • Autoimmune disorders: These may be associated with antibodies that predispose to a hypercoagulable state.

In a retrospective review of pediatric patients presenting to a pediatric emergency department, the most common risk factors identified for pulmonary embolism were BMI ≥ 25 kg/m2, oral contraceptive use, and history of previous pulmonary embolism.[15]

Previous
 
 
Contributor Information and Disclosures
Author

Lennox H Huang, MD, FAAP Associate Professor and Chair, Department of Pediatrics, McMaster University School of Medicine; Chief of Pediatrics, McMaster Children's Hospital

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

References
  1. David M, Andrew M. Venous thromboembolic complications in children. J Pediatr. 1993 Sep. 123(3):337-46. [Medline].

  2. Bernstein D, Coupey S, Schonberg SK. Pulmonary embolism in adolescents. Am J Dis Child. 1986 Jul. 140(7):667-71. [Medline].

  3. Kotsakis A, Cook D, Griffith L, et al. Clinically important venous thromboembolism in pediatric critical care: a Canadian survey. J Crit Care. 2005 Dec. 20(4):373-80. [Medline].

  4. Van Ommen CH, Peters M. Acute pulmonary embolism in childhood. Thromb Res. 2006. 118(1):13-25. [Medline].

  5. Evans DA, Wilmott RW. Pulmonary embolism in children. Pediatr Clin North Am. 1994 Jun. 41(3):569-84. [Medline].

  6. Rajpurkar M, Warrier I, Chitlur M, et al. Pulmonary embolism-experience at a single children's hospital. Thromb Res. 2007. 119(6):699-703. [Medline].

  7. Babyn PS, Gahunia HK, Massicotte P. Pulmonary thromboembolism in children. Pediatr Radiol. 2005 Mar. 35(3):258-74. [Medline].

  8. Cook A, Shackford S, Osler T, et al. Use of vena cava filters in pediatric trauma patients: data from the National Trauma Data Bank. J Trauma. 2005 Nov. 59(5):1114-20. [Medline].

  9. Baird JS, Killinger JS, Kalkbrenner KJ, Bye MR, Schleien CL. Massive pulmonary embolism in children. J Pediatr. 2010 Jan. 156(1):148-51. [Medline].

  10. Biss TT, Brandao LR, Kahr WH, Chan AK, Williams S. Clinical features and outcome of pulmonary embolism in children. Br J Haematol. 2008 Jun 17. [Medline].

  11. Vichinsky EP, Neumayr LD, Earles AN, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group. N Engl J Med. 2000 Jun 22. 342(25):1855-65. [Medline].

  12. van den Heuvel-Eibrink MM, Lankhorst B, Egeler RM, Corel LJ, Kollen WJ. Sudden death due to pulmonary embolism as presenting symptom of renal tumors. Pediatr Blood Cancer. 2008 May. 50(5):1062-4. [Medline].

  13. Dollery CM. Pulmonary embolism in parenteral nutrition. Arch Dis Child. 1996 Feb. 74(2):95-8. [Medline].

  14. Nuss R, Hays T, Chudgar U, Manco-Johnson M. Antiphospholipid antibodies and coagulation regulatory protein abnormalities in children with pulmonary emboli. J Pediatr Hematol Oncol. 1997 May-Jun. 19(3):202-7. [Medline].

  15. Agha BS, Sturm JJ, Simon HK, Hirsh DA. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013 Oct. 132(4):663-7. [Medline].

  16. Lee EY, Tse SK, Zurakowski D, et al. Children suspected of having pulmonary embolism: multidetector CT pulmonary angiography--thromboembolic risk factors and implications for appropriate use. Radiology. 2012 Jan. 262(1):242-51. [Medline].

  17. Lee EY, Zurakowski D, Boiselle PM. Pulmonary embolism in pediatric patients survey of CT pulmonary angiography practices and policies. Acad Radiol. 2010 Dec. 17(12):1543-9. [Medline].

  18. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990 May 23-30. 263(20):2753-9. [Medline].

  19. Revel MP, Sanchez O, Couchon S, et al. Diagnostic accuracy of magnetic resonance imaging for an acute pulmonary embolism: results of the 'IRM-EP' study. J Thromb Haemost. 2012 May. 10(5):743-50. [Medline].

  20. Goldenberg NA, Durham JD, Knapp-Clevenger R, Manco-Johnson MJ. A thrombolytic regimen for high-risk deep venous thrombosis may substantially reduce the risk of postthrombotic syndrome in children. Blood. 2007 Jul 1. 110(1):45-53. [Medline].

  21. Raffini L, Cahill AM, Hellinger J, Manno C. A prospective observational study of IVC filters in pediatric patients. Pediatr Blood Cancer. 2008 Jun 16. [Medline].

  22. Hull RD, Raskob GE, Brant RF, et al. Low-molecular-weight heparin vs heparin in the treatment of patients with pulmonary embolism. American-Canadian Thrombosis Study Group. Arch Intern Med. 2000 Jan 24. 160(2):229-36. [Medline].

  23. Faustino EV, Patel S, Thiagarajan RR, Cook DJ, Northrup V, Randolph AG. Survey of pharmacologic thromboprophylaxis in critically ill children. Crit Care Med. 2011 Jul. 39(7):1773-8. [Medline]. [Full Text].

  24. Baird JS, Greene A, Schleien CL. Massive pulmonary embolus without hypoxemia. Pediatr Crit Care Med. 2005 Sep. 6(5):602-3. [Medline].

  25. Beitzke A, Zobel G, Zenz W, et al. Catheter-directed thrombolysis with recombinant tissue plasminogen activator for acute pulmonary embolism after fontan operation. Pediatr Cardiol. 1996 Nov-Dec. 17(6):410-2. [Medline].

  26. Brandao LR, Labarque V, Diab Y, Williams S, Manson DE. Pulmonary embolism in children. Semin Thromb Hemost. 2011 Oct. 37(7):772-85. [Medline].

  27. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest. 2001 Jan. 119(1 Suppl):176S-193S. [Medline]. [Full Text].

  28. Kossel H, Bartsch H, Philippi W, et al. Pulmonary embolism and myocardial hypoxia during extracorporeal membrane oxygenation. J Pediatr Surg. 1999 Mar. 34(3):485-7. [Medline].

  29. Kossoff EH, Poirier MP. Peripherally inserted central venous catheter fracture and embolization to the lung. Pediatr Emerg Care. 1998 Dec. 14(6):403-5. [Medline].

  30. Macartney CA, Chan AK. Thrombosis in children. Semin Thromb Hemost. 2011 Oct. 37(7):763-1. [Medline].

  31. McCrory MC, Brady KM, Takemoto C, Tobias JD, Easley RB. Thrombotic disease in critically ill children. Pediatr Crit Care Med. 2010 Feb 11. [Medline].

  32. Monagle P, Chan A, DeVeber G. Andrew's Pediatric Thromboembolism and Stroke. 3rd ed. Ontario, Canada; BC Decker: 2006.

  33. Sandoval JA, Sheehan MP, Stonerock CE, Shafique S, Rescorla FJ, Dalsing MC. Incidence, risk factors, and treatment patterns for deep venous thrombosis in hospitalized children: an increasing population at risk. J Vasc Surg. 2008 Apr. 47(4):837-43. [Medline].

  34. Tay ET, Stone MB, Tsung JW. Emergency ultrasound diagnosis of deep venous thrombosis in the pediatric emergency department: a case series. Pediatr Emerg Care. 2012 Jan. 28(1):90-5. [Medline].

  35. Truitt AK, Sorrells DL, Halvorson E, et al. Pulmonary embolism: which pediatric trauma patients are at risk?. J Pediatr Surg. 2005 Jan. 40(1):124-7. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.