Evidence map›Paper›PMID 42398511›Full record

Observational studyThe Lancet. Respiratory medicine2026

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

Angela M Ellison, Nathan Kuppermann, Bashar S Shihabuddin, Hilary Hickingbotham, Allison Cator, Tamar R Lubell, Erin Hoehn, Karen J O'Connell, Sandra Spencer, Corrie E Chumpitazi and 15 more

Abstract readMulticenter StudyObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in The Lancet. Respiratory medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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0citing papers in PubMed
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1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

0 citing papers in PubMed.

No citing paper in PubMed yet.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

25 authors.

Angela M EllisonDepartment of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Nathan KuppermannChildren's National Hospital, Washington, DC, USA; Department of Pediatrics, GWU School of Medicine and Health Sciences, Washington, DC, USA; Department of Emergency Medicine, GWU School of Medicine and Health Sciences, Washington, DC, USA.
Bashar S ShihabuddinDivision of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Ohio State College of Medicine, The Ohio State University, Columbus, OH, USA.
Hilary HickingbothamUtah Data Coordinating Center, University of Utah, Salt Lake City, UT, USA.
Allison CatorDepartment of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
Tamar R LubellDepartment of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
Erin HoehnDepartment of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
Karen J O'ConnellChildren's National Hospital, Washington, DC, USA; Department of Pediatrics, GWU School of Medicine and Health Sciences, Washington, DC, USA; Division of Emergency Medicine, Children's National Hospital, Washington, DC, USA.
Sandra SpencerDepartment of Pediatrics, Children's Hospital of Colorado, Denver, CO, USA.
Corrie E ChumpitaziDepartment of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
Kara HennellyWashington University School of Medicine, St Louis, MS, USA; Department of Pediatrics, St Louis Children's Hospital, St Louis, MS, USA.
Ron KaplanDivision of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Seattle Children's, Seattle, WA, USA.
Matthew A EisenbergDivision of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA; Department Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
Elizabeth C PowellAnn and Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Laura MercurioThe Warren Alpert Medical School of Brown University, Providence, RI, USA.
Lauren C RineyDepartment of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA; Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Tiffani J JohnsonDepartment of Emergency Medicine, University of California Davis, Sacramento, CA, USA.
Michael D JohnsonPrimary Children's Hospital, Salt Lake City, UT, USA; Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
Amanda BogieDepartment of Pediatrics, University of Oklahoma, Norman, OK, USA.
Megan SchultzChildren's Wisconsin, Milwaukee, WI, USA; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
Jenny MendelsonDepartment of Pediatrics, University of Arizona, Tucson, AZ, USA.
Amy M DeLarocheDivision of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.
Jonathan RaceDepartment of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA; Emergency Medical Services for Children Data Center, Salt Lake City, UT, USA.
T Charles CasperDepartment of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA; Emergency Medical Services for Children Data Center, Salt Lake City, UT, USA.
Jeffrey A KlineDepartment of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA. Electronic address: jkline@wayne.edu.

Funding

BEdside Exclusion of Pulmonary Embolism in children without Radiation (BEEPER)R01HL148247 · NHLBI · WAYNE STATE UNIVERSITY · PI ELLISON, ANGELA M, KLINE, JEFFREY A · 2020 to 2024
$8.4M
NHLBI NIH HHS R01 HL148247
6 · The paper itself

Abstract

backgroundIn 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.

methodsThis 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%.

findingsBetween 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).

interpretationIn 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.

fundingUS National Institutes of Health.

Indexed as

Clinical Decision RulesPoint-of-Care TestingPulmonary EmbolismAdolescentChildChild, PreschoolEmergency Service, HospitalFemaleFibrin Fibrinogen Degradation ProductsHumansMaleProspective StudiesUnited StatesFibrin Fibrinogen Degradation Productsfibrin fragment D

Identifiers

PMID42398511
PMCPMC13545990

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.