WHAT'S KNOWN ON THIS SUBJECT: Pulmonary embolism (PE) in the pediatric population is rare but does occur and is underrecognized. In adult emergency medicine, there are validated clinical decision rules derived to provide reliable and reproducible means of determining pretest probability of PE. WHAT THIS STUDY ADDS:There are known risk factors, signs, and symptoms that should raise the clinician' s suspicion of pulmonary embolism, even in the pediatric population. abstract OBJECTIVE: To describe patients who present to the pediatric emergency department (PED) and are subsequently diagnosed with pulmonary embolism (PE). METHODS:Electronic medical records from 2003 to 2011 of a tertiary care pediatric health care system was retrospectively reviewed to identify patients ,21 years who had a final International Classification of Diseases, Ninth Revision diagnosis of PE. Patient demographics, and hospital course were recorded. Adult validated clinical decision rules Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) were retrospectively applied. PERC identified 8 clinical criteria for adult patients using logistic regression modeling to exclude PE without additional diagnostic evaluation. If all criteria are met, further evaluation is not indicated. RESULTS:Of 1 185 794 PED visits, 105 patients had an ultimate diagnosis of PE. Twenty-five met study criteria, and all were admitted. Forty percent of these patients had PE diagnosed in the PED. The most common risk factors were BMI $25 (50%, 10 of 20), oral contraceptive use (38% 5 of 13 female patients), and history of previous thrombus without PE (28%, 7 of 25). When the PERC rule was applied retrospectively, 84% of patients could not be ruled out, indicating additional evaluation for PE was needed.CONCLUSIONS: Pulmonary embolism is rare in children but does occur. This study emphasizes risk factors among children that should raise the suspicion of PE. Additional studies are needed to further evaluate risk factors and signs and symptoms of PE to develop pediatric specific clinical decision rules to provide reliable and reproducible means of determining pretest probability of PE. Pediatrics

We describe the clinical presentation, radiographic findings, management, and outcome of nontraumatic spinal epidural hematoma in a 10-month-old male infant with severe hemophilia (<1% activity). This patient presented with torticollis, and the differential diagnosis included intramuscular hemorrhage, retropharyngeal abscess, muscle spasm, and epidural hematoma. A computed tomography scan revealed extensive spinal epidural hematoma from C1-L4. Because of prompt diagnosis, this infant was able to be managed conservatively with factor VIII and did not require surgical intervention. Unlike other cases previously published, this case demonstrates how prompt recognition, diagnosis, and treatment can prevent the development of neurological deficits.

Ingestion of multiple magnets may cause serious gastrointestinal morbidity, such as pressure necrosis, perforation, fistula formation, or intestinal obstruction due to forceful attraction across bowel wall. Although the consequences of multiple magnet ingestion are well documented in young children, the current popularity of small, powerful rare-earth magnets marketed as "desk toys" has heightened this safety concern in all pediatric age groups. A recent US Consumer Product Safety Commission product-wide warning additionally reports the adolescent practice of using toy high-powered, ball-bearing magnets to simulate tongue and lip piercings, a behavior that may increase risk of inadvertent ingestion. We describe 2 cases of older children (male; aged 10 and 13 years, respectively) with unintentional ingestion of multiple rare-earth magnets. Health care providers should be alerted to the potential for misuse of these high-powered, ball-bearing magnets among older children and adolescents.