PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study
A negative PERC-Peds rule safely ruled out pulmonary embolism in selected emergency-department children.
*Prospective diagnostic accuracy cohort; Level 2 (OCEBM).
Citation
Ellison AM, Kuppermann N, Shihabuddin BS, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER). Lancet Respir Med. 2026;14:694-703.
Background
Children with possible pulmonary embolism often undergo blood testing or imaging despite limited pediatric evidence. Imaging can expose children to radiation and contrast risks, so a safe bedside rule could reduce low-value testing.
Patients
Children aged 4-17 years in 21 U.S. pediatric emergency departments when clinicians ordered or strongly considered testing for pulmonary embolism. Exclusions included known pregnancy, current anticoagulant use for clot disease, intoxication, incarceration, or inability to complete follow-up.
Intervention
Pulmonary Embolism Rule-Out Criteria in Children, assessed at the bedside.
Control
Final adjudicated diagnosis using imaging reports, records, and follow-up.
Outcome
Any pulmonary embolism or large deep vein clot within 45 days.
Follow-up Period
45 days; 90 days for children diagnosed with clots.
Results
| Finding | Result |
|---|---|
| Clot prevalence | 6.3% (95% CI 5.6 to 7.2) |
| PERC-Peds sensitivity | 99.6% (95% CI 97.8 to 100.0) |
| PERC-Peds specificity | 19.6% (95% CI 18.4 to 20.9) |
| False-negative rate | 0.1% (95% CI 0.0 to 0.8) |
| PERC-Peds then D-dimer | Ruled out 54.3%; false-negative rate 0.9% (95% CI 0.6 to 1.4) |
PERC-Peds: Pulmonary Embolism Rule-Out Criteria in Children. D-dimer: blood test for clot breakdown.
The primary analysis used adjudicated children with complete rule data. This was not a management trial.
Limitations
Low specificity means many children still tested positive by the rule. Results came from academic pediatric emergency departments and may not generalize. Agreement between clinicians was only modest, especially for clinical judgment. Possible indication creep: the evidence comes from children already considered at risk, not all children with chest pain or shortness of breath.
Funding
U.S. National Institutes of Health; no funder role reported.
Clinical Application
Use PERC-Peds only in selected emergency children with suspected pulmonary embolism to avoid unnecessary testing when all criteria are negative.
Discussion
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In this multicentre prospective observational diagnostic accuracy study, PERC-Peds negativity for suspected pediatric PE had sensitivity 99.6% and a false-negative rate of 0.1% for 45-day PE/proximal DVT. Given the non-management design, would you apply it to reduce imaging, and what validity/applicability concerns matter most? In this diagnostic accuracy study, PERC-Peds had sensitivity 99.6% and specificity 19.6% for 45-day PE/proximal DVT. Which statement best describes the clinical meaning of high sensitivity in this context?