Tension Gastrothorax in a Child Presenting with Abdominal Pain

A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She had suffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs were appropriate for age. Physical examination was remarkable for decreased breath sounds to the left side of the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of the chest with mediastinal shift

Do all infants with apparent life-threatening events need to be admitted?

OBJECTIVE. The goal was to identify criteria that would allow low-risk infants presenting with an apparent life-threatening event to be discharged safely from the emergency department. METHODS. We completed data forms prospectively on all previously healthy patients <12 months of age presenting to the emergency department of an urban tertiary care children's hospital with an apparent life-threatening event over a 3-year period. These patients were then observed for subsequent events, significant interventions, or final diagnoses that would have mandated their admission (eg, sepsis). RESULTS. In our population of 59 infants, all 8 children who met the aforementioned outcome measures, thus requiring admission, either had experienced multiple apparent life-threatening events before presentation or were in their first month of life. In our study group, the high-risk criteria of age of <1 month and multiple apparent life-threatening events yielded a negative predictive value of 100% to identify the need for hospital admission. CONCLUSIONS. Our study suggests that >30-day-old infants who have experienced a single apparent life-threatening event may be discharged safely from the hospital, which would decrease admissions by 38%

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction: Violence against healthcare workers in the medical setting is common and associatedwith both physical and psychological adversity. The objective of this study was to identify featuresassociated with assailants to allow early identification of patients at risk for committing an assault inthe healthcare setting.Methods: We used the hospital database for reporting assaults to identify cases from July 2011through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical andsocial history, primary medical complaints, ED diagnoses, medications prescribed, presence ofan involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, andfrequency of visits to same hospital requesting prescription for pain medications. We selectedmatched controls at random for comparison. The primary outcome measure(s) reported are featuresof patients committing an assault while undergoing medical or psychiatric treatment within themedical center.Results: We identified 92 novel visits associated with an assault. History of an involuntarypsychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED ona prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (orconsideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history ofillicit drug use in 33%. Compared with matched controls, all these factors were significantly different.Conclusion: Patients with obvious risk factors for assault, such as history of assault, psychosis, andinvoluntary psychiatric holds, have a substantially greater chance of committing an assault in thehealthcare setting. These risk factors can easily be identified and greater security attention given tothe patient

Need for Intervention in Families Presenting to the Emergency Department with Multiple Children as Patients

Introduction: To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child.Methods: This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation &gt; 6 hours) “critical interventions” and compared them separately.Results: In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P &lt; 0.0001).Conclusion: Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider. [West J Emerg Med. 2013;14(5):525–528.

Need for Intervention in Families Presenting to the Emergency Department with Multiple Children as Patients

INTRODUCTION: To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child. METHODS: This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation > 6 hours) “critical interventions” and compared them separately. RESULTS: In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P < 0.0001). CONCLUSION: Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider

Need for Intervention in Families Presenting to the Emergency Department with Multiple Children as Patients

Introduction: To assess if families presenting to a pediatric emergency department (PED) with multiple children as patients require interventions at the same rate as families presenting with a single child.Methods: This is a retrospective chart review looking at PED encounters for families presenting with single children versus multiple children as patients. Patients presenting with siblings were retrospectively selected from the electronic tracking board, and we randomly selected age/gender matched single-patient controls from a comparable time period. The primary outcome was a comparison of visit acuity between families presenting with single versus multiple children, with the hypothesis that families presenting with multiple children as patients would require less utilization of services (as a surrogate for acuity). Admission, intravenous fluid administration (IVF), planned observation, subspecialty consultation, performance of procedures, laboratories and radiographs, administration of prescription medications, and prescription medications for home were all recorded and compared via chi-squared comparison. We considered 5 interventions (admission, subspecialty consultation, performance of procedures, IVF administration, and observation &gt; 6 hours) “critical interventions” and compared them separately.Results: In our sample of 83 patients from 41 families registering multiple children and 248 singleton controls, we found a significant difference in the percentage of patients requiring critical interventions (4.8% versus 32.5%, P &lt; 0.0001).Conclusion: Families presenting with multiple children concurrently to an ED require critical interventions at a much lower rate than children presenting as single patients. Many of these families could be well-served at an urgent care or primary care provider. [West J Emerg Med. 2013;14(5):525–528.

Tension Gastrothorax in a Child Presenting with Abdominal Pain

A 4-year-old girl was brought to our hospital by her parents because of abdominal pain. She hadsuffered minor trauma after rolling from her standard-height bed 2 days prior. Vital signs wereappropriate for age. Physical examination was remarkable for decreased breath sounds to the left sideof the chest. A chest radiograph (Figure) demonstrated a large gas-filled structure in the left side of thechest with mediastinal shift. [West J Emerg Med. 2012;13(1):117–118.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction: Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting. Methods: We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center. Results: We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different. Conclusion: Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient