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PED-EM-L  December 2015

PED-EM-L December 2015

Subject:

Re: ALTE

From:

james reingold <[log in to unmask]>

Reply-To:

james reingold <[log in to unmask]>

Date:

Thu, 3 Dec 2015 08:18:55 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (186 lines)

I really appreciate everyone sharing their expertise and clinical approach.  I agree the CPG will be helpful as there is clearly some variation in practice.
In my experience much more than 75% of these infants present with the usual gagging/gasping/choking (obstructive apnea) rather than limp and not breathing (central), in my ED easily 90%+ are obstructive, with almost 100% being back to normal by time of my exam.  The few that have central apnea because of sepsis are generally obvious and continuing to have apnea in the ED.
So it would seem to me that the useful screening items would be those infants who are having repeated spells, premature, young age.  There's also a fair share of parents who are just too shaken up to go home, many mothers tell me they are too afraid to go to sleep because they are worried the baby "will not wake up in the morning."  Despite knowing that hospitalization is not risk-free, sometimes in that setting an overnight stay is worth it in my book.
James

> Date: Thu, 3 Dec 2015 14:19:59 +0000
> From: [log in to unmask]
> Subject: Re: ALTE
> To: [log in to unmask]
> 
> Hi Darrell,
> You raise good points
> ALTE is better considered as a presenting complaint or a description of an event. It may not be the final diagnosis.
> 75% of the infants in our single-center study had a completely normal examination by the time they presented to the ED. This group certainly has a much better prognosis.
> A sick looking infant who had an event at home that met the definition of ALTE has to be managed appropriate for a "sick looking infant", with the usual work-up till a cause is identified.
> 
> The NIH definition does not distinguish the majority of infants who appear well after an episode from sick-looking infants, and cases with choking/gagging from those with central apnea.
> Hopefully the Clinical Practice Guideline Subcommittee on ALTE, established by AAP in 2013 will revise the definition and provide evidence based guidelines for managing it.
> 
> Thanks,
> Manoj
> 
> Manoj Mittal, MD
> CHOP
> 
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Darrell Looney <[log in to unmask]>
> Sent: Thursday, December 3, 2015 1:02 AM
> To: [log in to unmask]
> Subject: Re: ALTE
> 
> This is truly a great discussion thread guys!
> As I read the studies and commentary by folks here, it seems a commonality is that for those patients presenting with ALTE and the evaluation panel identifying some underlying clinical cause, we can assign a higher risk for mortality than the cohort with no (or less) ominous etiologies (such as gagging). Would it seem reasonable to use the presence or absence of a clinical cause for the event as more evidence to admit or not? Also, in those cases with an identifiable clinical cause, is the case being coded as an ALTE or as the clinical entity which caused the ALTE (perhaps with ALTE as a second diagnosis)?
> Thanks!
> Darrell
> 
> *****************************************************Support the music you love or it goes away!Da Phatfunk CliqueDPC on RadioAirplay!DPC on Twitter!"Like" us on Facebook!
> 
> > Date: Wed, 2 Dec 2015 21:52:16 +0000
> > From: [log in to unmask]
> > Subject: Re: ALTE
> > To: [log in to unmask]
> >
> > Thanks, Jay.  I think your article serves to remind us that this is a fragile population in whom bad outcomes can be very difficult to predict from a single ED visit.  However, I still have a hard time with your conclusions.  The first question (which I posed earlier) is whether a one day hospital admission, which is probably the LOS for nearly all ALTE's that don't have any concerning historical or PE features, can actually serve to prevent the bad outcome.  The second question, which may be equally important, is whether an inpatient hospitalization has any negative impact on this vulnerable population.  Interesting that the two mortalities were deemed infectious at autopsy...might one or both of them have been hospital-acquired?
> >
> > To be clear, I am not advocating for universal discharge of these patients.  However, if we are talking about any event that is frightening to the observer and has a color change, choking, gagging, etc, etc, then we are including a lot of patients who had an obvious gagging episode related to feeding.  Exposing all of these patients to the inpatient hospital environment is very likely to lead to unintended negative consequences.  I am simply suggesting that having a thoughtful approach that weighs the pros and cons of admission is sure to be more effective than universal admission.
> >
> > As an aside, we don't admit neonates with a negative LP simply because of the risk of bacterial meningitis.  We admit the youngest of neonates, because we know that all of our available data (well appearance, normal UA, CBC, and CSF studies) has been shown to miss a very significant portion of serious bacterial infections in this age group, which can be cured by intravenous antibiotics...a clear rationale for inpatient admission despite the inherent risks of hospitalization.
> >
> >
> > Jeff
> >
> >
> >
> > ________________________________
> > From: [log in to unmask] <[log in to unmask]> on behalf of Jay Fisher <[log in to unmask]>
> > Sent: Wednesday, December 2, 2015 4:35 PM
> > To: Seiden, Jeffrey A
> > Cc: [log in to unmask]
> > Subject: Re: ALTE
> >
> > Jeff- Thanks for your thoughts.
> >
> > Agree that admission did not change the outcome of these kids, but the point we were trying to make with this study is that the near-term mortality in this population is quite high (at least in my population). Most of the the literature, in my view, has been too dismissive of this presentation given the small number of patients studied.
> >
> > What other presentations that you could potentially discharge from the Peds ED (we admitted virtually all during the study period) have a short term mortality of 1 percent?
> >
> > In fact, I think there are few Peds ED presentations that are managed as outpatients with a 0.1% mortality.
> >
> > In an era where the rule in rate for MI is 2-3%, and bacterial meningitis is present in less than 1 in a 100 febrile newborns with a negative LP (and who all get admitted), I don't see the logic in in discharging patients with an ALTE that meets the NIH definition.
> >
> > Thanks- Jay
> >
> >
> >
> > On Wed, Dec 2, 2015 at 1:00 PM, Seiden, Jeffrey A <[log in to unmask]<mailto:[log in to unmask]>> wrote:
> > While I certainly agree that these babies need to be evaluated carefully, this article does not convince me that universal inpatient admission is warranted. After all, every patient in this study WAS admitted! The real question is whether the short-term mortality rate would be different in this group compared with a cohort in which admission was considered more selectively, based on age, other historical features (prematurity, relation to gagging episode, etc), and exam findings.
> >
> > Jeff
> >
> > > On Dec 2, 2015, at 1:48 PM, Jay Fisher <[log in to unmask]<mailto:[log in to unmask]>> wrote:
> > >
> > > I am in your camp James - I think this is a high risk group that decision
> > > algorithms will miss in a small but recurring percentage of patients.- see
> > > below
> > >
> > > Jay Fisher MD FAAP
> > > Medical Director of Pediatric EM
> > > Children's Hospital of Nevada
> > >
> > > Am J Emerg Med. <http://www.ncbi.nlm.nih.gov/pubmed/23399327#> 2013
> > > Apr;31(4):730-3. doi: 10.1016/j.ajem.2013.01.002. Epub 2013 Feb 8
> > > Mortality after discharge in clinically stable infants admitted with a
> > > first-time apparent life-threatening event.
> > > Kant S
> > > <http://www.ncbi.nlm.nih.gov/pubmed/?term=Kant%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23399327>
> > > 1, Fisher JD
> > > <http://www.ncbi.nlm.nih.gov/pubmed/?term=Fisher%20JD%5BAuthor%5D&cauthor=true&cauthor_uid=23399327>,
> > > Nelson DG
> > > <http://www.ncbi.nlm.nih.gov/pubmed/?term=Nelson%20DG%5BAuthor%5D&cauthor=true&cauthor_uid=23399327>,
> > > Khan S
> > > <http://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23399327>
> > > .
> > > Author information <http://www.ncbi.nlm.nih.gov/pubmed/23399327#>
> > > AbstractOBJECTIVE:
> > >
> > > The objective of this study is to review the mortality after discharge in
> > > clinically stable infants admitted with a first apparent life-threatening
> > > event.
> > > METHODS: DESIGN:
> > >
> > > Retrospective chart review of all infants 0 to 6 months presenting with a
> > > first apparent life-threatening event (ALTE) over a 5-year period using
> > > explicit criteria. Patients with an emergency department (ED) diagnosis of
> > > ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3
> > > physicians. Level of agreement between reviewers was monitored. Mortalities
> > > were identified by a review of the county death record database and
> > > hospital records.
> > > RESULTS:
> > >
> > > Three hundred sixty-six charts were reviewed; 176 cases met inclusion
> > > criteria. All apparent life-threatening event (ALTE) cases were admitted; 1
> > > signed out against medical advice. Blood cultures were obtained in 111
> > > patients (63%)-no pathogens were identified. Cerebrospinal fluid analysis
> > > and culture was performed in 65 patients (37%)-no pathogens were
> > > identified. One patient had pleocytosis. Chest radiographs were obtained in
> > > 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial
> > > virus nasal washings were obtained in 32% of patients and were positive in
> > > 9 patients. The average length of follow-up was 34 months; 2 patients
> > > (1.1%) had died at the time of follow-up. Both deaths occurred after
> > > hospital discharge and within 2 weeks of the ED visit. Neither of the
> > > fatalities had a positive diagnostic evaluation in the ED. The cause of
> > > death by coroner report was pneumonia in both instances.
> > > CONCLUSIONS:
> > >
> > > The risk of subsequent mortality in infants admitted from our pediatric ED
> > > with an ALTE is substantial. Emergency physicians should consider routine
> > > admission for patients with ALTE.
> > >
> > >
> > > On Wed, Dec 2, 2015 at 9:09 AM, james reingold <[log in to unmask]<mailto:[log in to unmask]>>
> > > wrote:
> > >
> > >> Hello Colleagues,
> > >> I find I am getting increased resistance to admitting infants with ALTE
> > >> diagnosis, likely as administration gets more concerned about poor
> > >> reimbursement for observation status admissions.
> > >> I have two questions.
> > >> 1.  How do you decide which infants who have had a spell require admit?2.
> > >> Do you perform any studies in the ED for the vast majority of infants who
> > >> are back to baseline by the time of their arrival to the ED and have normal
> > >> vital signs and a normal exam?
> > >>
> > >> Thanks,James
> > >>
> > >>
> > >> For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the
> > >> message: info PED-EM-L
> > >> The URL for the PED-EM-L Web Page is:
> > >>                 http://listserv.brown.edu/ped-em-l.html
> > >
> > > For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L
> > > The URL for the PED-EM-L Web Page is:
> > >                 http://listserv.brown.edu/ped-em-l.html
> >
> > For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                  http://listserv.brown.edu/ped-em-l.html
> >
> >
> > For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                  http://listserv.brown.edu/ped-em-l.html
> 
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
> 
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
 		 	   		  
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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