PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study.

Abstract

In emergency care, clinicians currently have scarce evidence-based guidance on whether to order diagnostic tests for suspected pulmonary embolism in children. We aimed to test whether the Pulmonary Embolism Rule-Out Criteria in Children (PERC-Peds) can safely rule out pulmonary embolism in children. This multicentre, prospective, observational, diagnostic accuracy study was done in 21 paediatric emergency departments across the USA. We enrolled children aged 4-17 years who presented with symptoms prompting the emergency physician to order, or strongly consider ordering, a diagnostic test for pulmonary embolism. Participants formed a consecutive series. At the point of care, clinicians completed a case report form to record the components of the PERC-Peds rule. Diagnostic testing, including D-dimer testing, was done at clinician discretion. Trained research personnel collected patient-reported demographic data, symptoms, medications, and past medical histories prospectively and cross-checked patient-reported past medical histories and medications against data in the electronic health record. Follow-up was done 45 days after enrolment with a standardised, automated SMS message to caregivers. The criterion standard for pulmonary embolism was the outcome of any venous thromboembolism (VTE; including image-proven pulmonary embolism or proximal deep vein thrombosis [DVT; above knee or elbow, but not including isolated saphenous, brachial, or calf vein clots]) within 45 days, as adjudicated by an independent committee of three board-certified paediatric emergency physicians. Adjudicators viewed all imaging reports, information from the 45-day follow-up, and outside medical records. The primary endpoint was safe exclusion by use of PERC-Peds in all participants who were adjudicated, defined as the upper limit of the 95% CI for the false-negative rate not crossing 1·5%. Between July 29, 2020, and Sept 29, 2024, 4039 children were enrolled, with 4011 participants adjudicated for pulmonary embolism or proximal DVT. Date of last follow-up was Sept 18, 2025. The median age of the adjudicated population was 15 years (IQR 13-16); 2567 (64·0%) were female and 1444 (36·0%) were male. 3988 participants had complete data, and 253 (6·3%, 95% CI 5·6-7·2) were diagnosed with pulmonary embolism or proximal DVT within 45 days. The sensitivity of the PERC-Peds rule was 99·6% (95% CI 97·8-100·0), specificity was 19·6% (18·4-20·9), and false-negative rate was 0·1% (0·0-0·8). D-dimer test was ordered in 3161 (78·8%) of 4011 participants. Sequential use of PERC-Peds followed by D-dimer test ruled out pulmonary embolism or proximal DVT in 2167 (54·3%) with a false-negative rate of 0·9% (0·6-1·4). In this multicentre, prospective, observational, diagnostic accuracy study of children with suspected pulmonary embolism in the emergency department, we found a 6·3% prevalence of pulmonary embolism or proximal DVT; in this population, the PERC-Peds negative rule can safely rule out pulmonary embolism. Use of PERC-Peds might reduce low-value diagnostic testing for pulmonary embolism in children and adolescents. US National Institutes of Health.