Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs.

INTRODUCTION: Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events. METHODS: We performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event. RESULTS: Of 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability. CONCLUSION: In our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.

Oropharyngeal Edema in an 8-Month-Old Girl after Woolly Bear Caterpillar Exposure.

BACKGROUND: Lepidopterism refers to the manifestations of contact from any number of moths, butterflies, and caterpillars. Various symptoms have been described, ranging from localized skin irritation to systemic anaphylactic reactions. CASE REPORT: We present a case of airway edema in an 8-month-old child from oral exposure to Woolly Bear Caterpillar (Pyrrharctia Isabella). After prompt emergency department recognition, her symptoms necessitated urgent operating room management by a team of otolaryngologists and close monitoring in a pediatric intensive care unit. A similar presentation in this species has not been described previously in the English literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Leptidopterism is rare, but recognition by the emergency practitioner is necessary for prompt and appropriate treatment. Rapid identification by the emergency physician of oral exposure and careful spine removal can be lifesaving in cases of significant oropharyngeal edema.

Effort thrombosis (Paget-Schroetter syndrome) in a 16-year-old male.

PATIENT: Male, 16. FINAL DIAGNOSIS: Effort thrombosis (Paget-Schroetter Sydnrome). SYMPTOMS: Swollen arms. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Metabolic Disorders and Diabetics. OBJECTIVE: Rare disease. BACKGROUND: Thrombotic events in otherwise healthy pediatric patients are rare. In patients presenting with limb swelling, thrombosis must be considered in the differential diagnosis. In pediatric patients with thrombosis, there has been wide variability in the rates of associated thrombophilia. Many pediatric patients may instead have other contributors such as venous catheters or physical activity. CASE REPORT: We present a case of bilateral upper extremity deep venous thrombi in a previously healthy 16-year-old male. The patient presented with swelling and pain in both arms after several days of weight-bearing exercise. Following emergency department evaluation with ultrasound and laboratory testing, the patient was diagnosed with effort thrombosis - also known as Paget-Schroetter syndrome - and rhabdomyolysis. CONCLUSIONS: This case of Paget-Schroetter syndrome is distinguished by elevation in creatine kinase and transaminases. While these findings can be due to physical exertion and effort, effort thrombosis is not classically associated with laboratory abnormalities except an elevated D-dimer. The significance of these laboratory test result abnormalities remains unclear. Given the rarity of effort thrombosis, further epidemiological study is warranted to determine if these laboratory findings are seen in other cases, and, if so, what implications they may have for management and prognosis.

Adverse events in pediatric ketamine sedations with or without morphine pretreatment.

OBJECTIVE: To assess outcomes between 2 groups of patients receiving ketamine for procedural sedations in our pediatric emergency department. Our hypothesis is that there is no difference in the number of adverse events in ketamine sedations with and without morphine pretreatment. METHODS: This was a retrospective cohort study of all ketamine sedation records over 15 months. The number and types of adverse events between patients with and without morphine pretreatment were examined. The numbers of adverse events in each group were compared using a z test. We also examined the possible influence of midazolam coadministration. P values were calculated using Pearson chi2 or Fisher exact tests. RESULTS: A set of 858 sedations were reviewed. Age, weight, and medication dosages were similar in each group. Twenty-one adverse events were recorded in the group of patients without morphine pretreatment. There were 13 adverse events in the group with morphine pretreatment. No significant differences were found for the number or types of events. There was no difference in the frequency of midazolam coadministration, Pearson chi2, P = 0.994, nor for the number of adverse events in each group, Fisher exact test, P = 0.465. The mean time from morphine administration to procedural sedation was 114.7 minutes. One adverse event occurred in the 15-minute or less time interval. CONCLUSIONS: We found no increase in the number of adverse events with morphine pretreatment in ketamine sedations for children. Prospective studies to validate these findings, including an effect of timing of analgesia administration, are warranted.