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
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.
1, Fisher JD
Author information <http://www.ncbi.nlm.nih.gov/pubmed/23399327#>
The objective of this study is to review the mortality after discharge in
clinically stable infants admitted with a first apparent life-threatening
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
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.
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]>
> 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?
> 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:
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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