The title says it all. I referenced this article on shift tonight for probably the third time and had to post it here so that I could keep track of it — this is a review of radiographic imaging and approaches to workup/management of various foreign bodies in both pediatrics and adults. It’s an excellent overview — it’s not the answer to a very specific question I saw another group publish in the 90s by Ell and Sprig, that taught us that “only the bones from cod, haddock, cole fish, gurnard, lemon sole, monk fish, grey mullet and red snapper are well seen by soft tissue radiographic techniques” — but it is still very useful in keeping these things straight. It has helpful images, algorithmic approaches to various types of suspected ingestions, and lots of references for more detailed information and studies. I would love it if Annals of EM would publish more stuff like this, even if it comes from outside our direct field.
Kaji et al. bring us “Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital”, which is pretty much what it sounds like. What did it leave us with? The study looked at 832 kids presenting w/ ALTE to four different sites and identified three variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most (but not all!) infants with apparent life-threatening events necessitating admission. I’ll just put that here again, in case you missed it: one of the conclusions was that obvious need for admission was a variable that predicted need for admission. Huh.
That point aside (and really, it’s a more interesting conclusion than it sounds like — meaning, that the ALTE kids who look sick when they get there tend to go on to have bad outcomes (hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection) discovered while in-hospital or receive some sort of “significant intervention” during their hospitalization that, retrospectively, necessitated admission. To be fair, the variable “obvious need for admission” was defined in the paper as occurring “if the child needed supplemental oxygen for non–self-resolving hypoxia, intubation, ventilation, cardiopulmonary resuscitation (CPR), intravenous antibiotics for a confirmed serious bacterial infection, or antiepileptic drugs (for status epilepticus); had hemodynamic instability warranting continuous intravenous fluids or vasopressors; or had a positive test result for respiratory syncytial virus or pertussis in the setting of an apparent life-threatening event.”
It would be difficult to argue against admitting any patient in one of these contexts (with the possible exception of non-self-solving hypoxia, which in the bronchiolitic child who is otherwise well-appearing should probably not serve in isolation as a reason to admit), and I imagine that such events occurring in the context of an ALTE are even more clear-cut indications for continued observation and management. Still, this is a nice body of literature showing that even with 84% of patients appearing well at time of ED presentation, 23% go onto need serious interventions once hospitalized — which is to say, being well-appearing at presentation does not protect against the need for escalation of care or therapeutic interventions soon thereafter.