Points & Pearls: Pediatric community-acquired pneumonia: diagnosis and management in the emergency department

Worldwide, pneumonia is the most common cause of death in children aged < 5 years. Distinguishing viral from bacterial causes of pneumonia is paramount to providing effective treatment but remains a significant challenge. For patients who can be managed with outpatient treatment, the utility of laboratory tests and radiographic studies, as well as the need for empiric antibiotics, remains questionable. This issue reviews viral and bacterial etiologies of community-acquired pneumonia in pediatric patients, offers guidance for obtaining historical information and interpreting physical examination findings, discusses the utility of various diagnostic techniques, and provides recommendations for the treatment of previously healthy and medically fragile children. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]

Pediatric community-acquired pneumonia: diagnosis and management in the emergency department.

Worldwide, pneumonia is the most common cause of death in children aged < 5 years. Distinguishing viral from bacterial causes of pneumonia is paramount to providing effective treatment but remains a significant challenge. For patients who can be managed with outpatient treatment, the utility of laboratory tests and radiographic studies, as well as the need for empiric antibiotics, remains questionable. This issue reviews viral and bacterial etiologies of community-acquired pneumonia in pediatric patients, offers guidance for obtaining historical information and interpreting physical examination findings, discusses the utility of various diagnostic techniques, and provides recommendations for the treatment of previously healthy and medically fragile children.

Primary Care and Emergency Department Management of the Patient With Duchenne Muscular Dystrophy.

Primary care providers (PCPs) are usually the first point of contact with the health care system for patients with Duchenne muscular dystrophy (DMD), and patients often present to emergency departments in which providers have little experience in dealing with this condition. With this article, we give primary care and emergency medicine providers a background in the common issues that affect people with DMD. By acquiring some specialized knowledge about the multisystem medical complications of DMD and by applying general principles of primary care, such as timely immunization, anticipatory safety counseling, behavioral screening, and routine nutritional and developmental assessments, the PCP can be a valued and effective medical provider to patients with DMD. The PCP can provide access to and effective coordination among the patient's specialty caregivers. Moreover, the PCP can become a trusted advisor to the patient and his family about important medical decisions, as well as issues in the psychosocial, behavioral, and educational domains. This article also contains a "pocket guide" used to assess and manage common urgent medical problems that cause patients with DMD to seek care in the emergency department. With the background information discussed in this article, both PCPs and emergency medicine physicians can skillfully care for patients with DMD in their respective settings, optimizing patient outcomes.

Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan.

Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy.

Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education.

BACKGROUND: Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates. METHODS: A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction. INTERVENTION: Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1-3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone. RESULTS: There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service. CONCLUSION: Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.

Serum biomarkers for identifying acute chest syndrome among patients who have sickle cell disease and present to the emergency department.

OBJECTIVE: To compare the accuracy of biomarkers for identifying acute chest syndrome (ACS) in patients with sickle cell disease presenting to a pediatric emergency department (ED). METHODS: We conducted a 13-month-long (2002-2003) cohort study with nested case-control in patients with sickle cell disease presenting to the pediatric ED with vaso-occlusive crises or fever in which we compared levels of secretory phospholipase A2 (sPLA2), endothelin-1, interleukin-6 (IL-6), and peripheral white blood cell count (WBC) in cases that were complicated by ACS and in control subjects with uncomplicated illnesses. For diagnosis, a test was considered to be accurate when the area under its receiver operator characteristic curve (AUC) was >0.70. Laboratory tests with AUC values > or =0.70 were entered into a binary recursive partitioning model for diagnosis. RESULTS: For the period of study, samples from 72 visits were obtained from 51 patients who presented with vaso-occlusive crises (range: 1-4 visits per patient; 15 were enrolled more than once). ACS complicated 19 of 72 visits (26%, 95% confidence interval: 17%-38%). At an AUC value of 0.79, only the sPLA2 test was accurate for diagnosing ACS. AUC values for peripheral WBC, endothelin-1, and IL-6 were 0.68, 0.51, and 0.52, respectively. Binary recursive partitioning retained only sPLA2 at a cutoff of 13.7 ng/mL to be accurate for diagnosis. This cutoff had a sensitivity of 74% (14 of 19), a specificity of 87% (46 of 53), a positive likelihood ratio of 5.6, and a negative likelihood ratio of 0.18. CONCLUSIONS: Secretory phospholipase A2 but not endothelin-1, IL-6, or WBC is an accurate test for identifying present or incipient ACS in young patients who present to the ED with sickle cell pain crises.