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ABSTRACT: STUDY OBJECTIVE: We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. METHODS: Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. RESULTS: A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). CONCLUSION: We found 3 variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.
Annals of emergency medicine 09/2012; · 4.23 Impact Factor
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ABSTRACT: The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases.
The authors prospectively evaluated the clinical guideline in one pediatric emergency department (ED) in a general teaching hospital. Patients were risk-stratified based on history, physical examination findings, and laboratory results. Imaging was ordered selectively based on risk category, with ultrasound (US) as the initial imaging modality. Computed tomography (CT) was ordered if the US was negative or indeterminate. Surgery was consulted before imaging in high-risk patients.
A total of 475 patients were enrolled. Of those, 193 (41%) had appendicitis. No low-risk patient had appendicitis. Medium-risk patients had a 19% rate of appendicitis, and 83% of high-risk patients had appendicitis. Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing's signs. Of the 475 patients, 276 (58%) were managed without a CT scan. Seventy-one of the 193 (37%) patients with appendicitis went to the operating room without any imaging. The rate of missed appendicitis was 2%, and the rate of negative appendectomy was 1%.
The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan.
Academic Emergency Medicine 07/2012; 19(8):886-93. · 1.86 Impact Factor
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ABSTRACT: To determine the percentage of cases of epididymitis in pediatric patients that is of bacterial cause and to identify factors that predict a positive urine culture.
We conducted a retrospective chart review of patients diagnosed with acute epididymitis or epididymo-orchitis in 1 pediatric emergency department for 11 years. Charts were reviewed for historical, physical, laboratory, and radiologic data. A positive urine culture was used to identify patients with a bacterial cause of epididymitis.
A total of 160 patient records were initially identified as having a diagnosis of epididymitis; of these, 20 met exclusion criteria or did not have records available for review and 140 cases of epididymitis were reviewed. Patients' age ranged from 2 months to 17 years, with a median age of 11 years. Of these patients, 91% received empiric antibiotic therapy. Also, of these patients, 97 (69%) had a urine culture sent, of whom 4 (4.1%; 95% confidence interval, 1.1%-10.2%) were positive. Of the 4 positive urine cultures, 3 had organisms not sensitive to usual empiric therapy for urinary tract infections. The boys with positive urine cultures were not significantly different from the other patients in age, maximum temperature, or number of white blood cells on urinalysis.
Given the low incidence of urinary tract infections in boys with epididymitis, in prepubertal patients, antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures. Because it is difficult to predict which patients will have a positive urine culture, urine cultures should be sent on all pediatric patients with epididymitis.
Pediatric emergency care 02/2011; 27(3):174-8. · 0.92 Impact Factor
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ABSTRACT: Pediatric airway problems are seen commonly in pediatric and general emergency departments, management of the pediatric airway is often stressful to providers. This article reviews the pediatric airway, highlighting the anatomic and physiologic differences between infant, pediatric and adult airways, and how these differences impact assessment and management of the pediatric airway.
Emergency medicine clinics of North America 12/2008; 26(4):961-75, ix. · 0.96 Impact Factor
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ABSTRACT: To determine the preparedness of pediatric offices that had activated emergency medical services (EMS) for a critically ill child requiring airway management.
Fifteen patients who initially presented to pediatric or family practice offices but required EMS activation and cardiac and/or respiratory support were identified from a previous prospective study of airway management in children. Two to 4 years after the emergency requiring EMS activation, the offices were contacted to complete a written survey about office preparedness for pediatric emergencies.
Eight of 15 offices (53%) returned a survey. Pediatricians staffed all responding offices, and all offices were within 5 miles of an emergency department. Airway emergencies were the most common emergencies seen in the offices. Availability of emergency equipment and medications varied. All offices stocked albuterol, and most (7/8) had an oxygen source with a flowmeter. However, only half of the offices had a fast-acting anticonvulsant, and a quarter had no anticonvulsant. Three offices lacked bag-mask (manual) resuscitators with all appropriate sized masks, and 3 offices lacked suction. The most common reasons cited for not stocking all emergency equipment and drugs were quick response time of EMS and proximity to an emergency department.
Even after treating a critically ill child who required advanced cardiac and/or pulmonary support, offices were ill prepared to handle another serious pediatric illness or injury.
Pediatric emergency care 12/2006; 22(11):694-8. · 0.92 Impact Factor
