Yield of Neurodiagnostic Testing in Children Presenting to a Pediatric Emergency Department With Altered Mental Status.

BACKGROUND: Emergency department (ED) visits for altered mental status (AMS) in children are common. Neuroimaging is often performed to ascertain etiology, but its utility has not been well studied. Our objective is to describe the yield of neuroimaging studies in children who present to an ED with AMS. METHODS: We performed a retrospective chart review of children 0-18 years of age, presenting to our PED between 2018 and 2021 with AMS. We abstracted patient demographics, physical examination, neuroimaging and EEG results, and final diagnosis. Neuroimaging and EEG studies were classified as normal or abnormal. Abnormal studies were categorized as clinically important and contributory: abnormalities that were clinically important and contributed to the etiology, clinically important but noncontributory: abnormalities that were clinically significant but did not explain the etiology, and incidental: abnormalities that were not clinically significant. RESULTS: We analyzed 371 patients. The most common etiology of AMS was toxicologic (188, 51%) with neurologic causes (n = 50, 13.5%) accounting for a minority. Neuroimaging was performed in one-half (169, 45.5%) and abnormalities were noted in 44 (26%) studies. Abnormalities were clinically important and contributed to the etiologic diagnosis of AMS in 15/169 (8.9%), clinically important and noncontributory in 18/169 (10.7%), and incidental in 11/169 (6.5%). EEG was performed in 65 patients (17.5%), of which 17 (26%) were abnormal with only one being clinically important and contributory. CONCLUSIONS: Though neuroimaging was performed in approximately one half of the cohort, it was contributory in a minority. Similarly, diagnostic utility of EEG in children with AMS was low.

Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended?

ABSTRACT: Fever is the most common complaint for infants and children brought to the emergency department. Most febrile children younger than 3 years will have a clinically apparent source of infection. However, in approximately 20% of these children, a source cannot be identified by history and physical examination alone. The recommended diagnostic approach to children younger than 3 years presenting with fever without source (FWS) has changed dramatically over the past 30 years because of the widespread use of the Haemophilus influenza type b and polyvalent pneumococcal vaccines. The percentage of children in the United States unvaccinated at 24 months is now over 1% and seems to be increasing. This article will review what is currently known about FWS in children aged 3 to 24 months in the modern era and how it pertains to unvaccinated children treated in the emergency department. An algorithm for the treatment of unvaccinated young children presenting with FWS is proposed.