Emergency medicine journal : EMJ
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More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission. ⋯ In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.
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Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. ⋯ 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.
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Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI. ⋯ Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.
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Telephone triage is increasingly used to manage unscheduled care demand. Younger adults are frequent users, and commonly call with chest pain. We compared pathways of care in younger adults calling with chest pain, and associations of patient characteristics and telephone triage recommendation with hospital admission. ⋯ Chest pain triage by NHS24 appears safe, but care pathways can involve multiple service contacts. While acuity assigned to the call is strongly related to the odds of hospital admission and odds of an 'acute-and-serious' diagnosis, 'overtriage' means few patients are directed to self-care advice.