Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department.

OBJECTIVES: A growing number of children receive support from left ventricular assist devices (LVADs) in the outpatient setting. Unexpected complications of LVAD support occur that require emergent management, and no studies examine how pediatric LVAD patients present to the emergency department (ED). The goals of this study were (1) to describe frequency of visits, clinical characteristics, adverse events, and outcomes of LVAD-supported children treated in ED settings and (2) to evaluate for associations between specified patient outcomes and ED care location. METHODS: This was a retrospective cohort study of children in a single-center outpatient VAD program who presented to several EDs during a 10-year period. We defined adverse events according to the Advanced Cardiac Therapies Improving Outcomes Network registry guidelines. Secondary analysis evaluated for associations between specified patient outcomes (adverse events, hospitalizations, intensive care unit admissions) and ED care location (institutional vs other ED). RESULTS: Of 104 subjects with LVAD implantations during the study period, 30 (28.8%) transitioned to outpatient care. Among subjects in the outpatient VAD program, 24 (80%) of 30 had 54 visits to various EDs over 141.9 patient-months. The median age at time of ED visit was 13.5 years (range, 7.2-17.9 years). The median number of visits per subject was 1 (range, 0-6). The most common complaints on arrival to the ED were vomiting or abdominal pain (16.7%), fever (15.3%), and headache (13.9%). Seventeen adverse events occurred during 14 (25.9%) of 54 ED visits. The most common adverse events were major infection (33.3%) and right heart failure (16.7%). Hospital admission resulted from 41 (75.9%) of 54 ED visits, including 17 (41.5%) of 41 to a cardiovascular intensive care unit. Care at a nonspecialty ED was associated with a higher rate of hospitalization (93.8% vs 68.4%, P = 0.049). During the study period, 4 subjects (13.3%) died, including 1 patient on destination therapy, 1 with multisystem organ failure due to cardiogenic shock, and 2 with hemorrhagic stroke. No patient died while in the ED. CONCLUSIONS: Among subjects in a single outpatient pediatric VAD program presenting to the ED, the most common complaints were abdominal pain/vomiting, fever, and headache. The most common adverse events were major infection and right heart failure. Subjects had a high rate of ED utilization and hospital admission.

Pott's Disease in a Patient with Subtle Red Flags.

BACKGROUND: Tuberculosis (TB) is now rare in developed countries; however, it is an important diagnosis for the Emergency Physician to be able to make. Classically thought of as a respiratory disease, TB can present in other ways, making it more challenging to recognize. CASE REPORT: We report the case of a 41-year-old woman who presented to the Emergency Department with a 4-week history of back pain. A diagnosis of T12 osteomyelitis and right psoas muscle abscess was made after magnetic resonance imaging. The concurrent finding raised concern for TB as psoas muscle abscess is usually found along with spinal TB. A computed tomography-guided fine-needle aspiration confirmed the diagnosis. This patient's social history was negative for many of the classic predisposing factors associated with TB: immunosuppression, personal travel, crowded living conditions. Repeated investigation into the patient's history revealed a visit several months prior from a family member from Vietnam who had been treated for TB. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important for Emergency Physicians to be aware of the relatively high incidence of TB as a cause for concurrent psoas abscess and vertebral osteomyelitis.