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Neonates and children represent a specific population that can suffer from deep venous thrombosis (DVT) and pulmonary embolism (PE). In considering how the diagnosis and management of DVT/PE in neonates and children differs from adults, one has to consider the fundamental differences in the general characteristics of the patient population, the specific differences in the disease entity, the differences in sensitivity or specificity of diagnostic strategies and risk/benefit profile of therapeutic options available, and then finally the practical applications of therapies, using an evidence-based approach.

This review will articulate the key differences in the patient population, disease entity, diagnostic strategies, and drug therapies that must be understood to apply a rigorous evidence-based approach to diagnosis and management of DVT and PE in neonates and children. Finally, there will be a brief discussion of the latest American College of Chest Physician guidelines for antithrombotic treatment in neonates and children.

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Venous thromboembolism (VTE) is a serious and potentially fatal medical condition. Correct diagnosis and early treatment of VTE with anticoagulant drugs are critical steps in preventing further complications and recurrence.

Evidence suggests that patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) should be managed with a diagnostic strategy that includes clinical pretest probability assessment, D-dimer test, and imaging. Clinical probability scoring, complemented by selective D-dimer testing, has become the recommended strategy for diagnosis. The reason is that overwhelming evidence suggests that patients with suspected VTE are better managed with a diagnostic strategy. If diagnostic algorithms are followed correctly, the chances of adverse events are extremely low (< 1%) in patients in whom VTE has been ruled out, whereas incomplete strategies leads to an increased risk of recurrent VTE or death.

This review focuses on the application of diagnostic strategies with suspected DVT or PE into daily clinical practice while discussing the benefits and disadvantages of different approaches.

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OBJECTIVE: To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care.

DESIGN: Prospective cohort study.

SETTING: Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).
PARTICIPANTS: 598 adults with suspected pulmonary embolism in primary care.
INTERVENTIONS: Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months' follow-up.

MAIN OUTCOME MEASURES: Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months.

RESULTS: Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.

CONCLUSION: A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.

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Acute pulmonary embolism (PE) is a common clinical condition with presentations that may vary from asymptomatic subsegmental emboli to massive vascular obstruction and shock with high risk of death. Identifying patients at highest risk for death is critical to select those who would benefit most from thrombolytic therapy.

New and evolving clinical prediction models, serum tests, and imaging modalities are being used to improve our ability to identify potential thrombolytic candidates.

We review the evolution of the present guidelines on the management of PE, specifically regarding the evolving role of thrombolytics; outcomes following thrombolytic therapy, including mortality, hemorrhage, hemodynamic improvement, and prevention of chronic thromboembolic pulmonary hypertension; and our strategy for risk stratification of pulmonary embolism.