Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event.

OBJECTIVE: The objective of this study is to review the mortality after discharge in clinically stable infants admitted with a first apparent life-threatening event. DESIGN: Retrospective chart review of all infants 0 to 6 months presenting with a first apparent life-threatening event (ALTE) over a 5-year period using explicit criteria. Patients with an emergency department (ED) diagnosis of ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3 physicians. Level of agreement between reviewers was monitored. Mortalities were identified by a review of the county death record database and hospital records. RESULTS: Three hundred sixty-six charts were reviewed; 176 cases met inclusion criteria. All apparent life-threatening event (ALTE) cases were admitted; 1 signed out against medical advice. Blood cultures were obtained in 111 patients (63%)-no pathogens were identified. Cerebrospinal fluid analysis and culture was performed in 65 patients (37%)-no pathogens were identified. One patient had pleocytosis. Chest radiographs were obtained in 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial virus nasal washings were obtained in 32% of patients and were positive in 9 patients. The average length of follow-up was 34 months; 2 patients (1.1%) had died at the time of follow-up. Both deaths occurred after hospital discharge and within 2 weeks of the ED visit. Neither of the fatalities had a positive diagnostic evaluation in the ED. The cause of death by coroner report was pneumonia in both instances. CONCLUSIONS: The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial. Emergency physicians should consider routine admission for patients with ALTE.

Closed reduction of distal forearm fractures by pediatric emergency physicians.

OBJECTIVES: The objective of this study was to determine if there exist differences in length of stay (LOS) in the emergency department (ED) and need for reintervention to restore alignment after distal forearm fracture reduction by pediatric emergency physicians (EPs) versus postgraduate year 3 or 4 orthopedic residents. METHODS: In a prospective trial at a busy urban pediatric ED, children with closed distal forearm fractures that met predefined criteria for manipulation were randomized to treatment by a postgraduate year 3 or 4 orthopedic resident or by a pediatric EP who had received focused training in forearm fracture reduction. Prereduction, postreduction, and follow-up radiographs were evaluated by an attending pediatric orthopedic surgeon who was unaware of the assigned group. The following outcomes were assessed: LOS during the initial ED encounter, adequacy of alignment immediately postreduction and at follow-up visits after discharge from the ED, the need for remanipulation, unscheduled ED visits, and radiographic healing at 6-8 weeks after injury. RESULTS: A total of 103 children were randomized into the pediatric EP (52 patients, mean age 9.1 years) and orthopedic resident (51 patients, mean age 9.7 years) groups. Patients in the two groups were similar in age, involvement of the physes, degree of angulation, percentage of displacement, and need for procedural sedation. The mean LOS in the ED was 4.5 hours in the pediatric EP group versus 5.0 hours in the orthopedic resident group (difference in means -0.5 hours, 95% confidence interval [CI] = -1.26 to 0.37 hours). Remanipulation was required in 4 of 48 (8.3%) in the pediatric EP group versus 6 of 48 (12.5%) in the orthopedic resident group (odds ratio [OR] = 0.64; 95% CI = 0.16 to 2.67). Unscheduled ED visits for cast-related problems occurred in 6 of 51 (11.8%) in the pediatric EP group and 4 of 52 (7.7%) in the orthopedic resident group (OR = 1.59; 95% CI = 0.38 to 6.39). None of these patients with unscheduled ED visits developed compartment syndrome or required admission. CONCLUSIONS: Length of stay in the ED and clinical outcomes after closed reduction of forearm fractures by trained pediatric EPs are comparable to those after closed reduction by orthopedic residents.