Immunization Status and the Management of Febrile Children in the Pediatric Emergency Department: What Are We Doing?

OBJECTIVES: Widespread Haemophilus influenzae and Streptococcus pneumoniae immunization has decreased occult bacteremia and bacterial meningitis rates. Practice has evolved in pediatric emergency departments (PEDs) to favor fewer diagnostic tests for and empiric treatment of invasive bacterial infection. We lack evidence-based guidance on evaluation and treatment of unimmunized (UnI) or underimmunized (UnderI) febrile children. This study aims to determine how parental report of immunization status in febrile PED patients impacts rates of diagnostic testing, interventions, and hospital admissions. METHODS: This is a retrospective cohort study with chart review of encounters of children aged 3 to 36 months presenting to an academic, tertiary care PED in 2019 using International Classification of Diseases-10 code for fever (R50.9). Inclusion criteria were documented fever of 38°C and higher and well appearance. Encounters were excluded if there was a history of chronic illness or documentation of ill appearance or hemodynamic instability. Encounters were grouped by provider-documented immunization status. Fischer exact test and logistic regression compared rates of diagnostic testing (serum, urine or cerebrospinal fluid laboratory studies, and chest radiographs), interventions (intravenous fluid bolus, intravenous antibiotic or steroid administration, respiratory support, or breathing treatment), and hospital admissions between UnderI, UnI, and fully immunized (FI) groups. RESULTS: Of the 1813 encounters reviewed, 1093 (60%) included provider-documented immunization status and 788 (43%) met final inclusion criteria: 23 (2.1%) UnI, 44 (5.8%) UnderI, and 721 (92.1%) FI. The UnderI and UnI children experienced significantly higher rates of laboratory evaluation including complete blood count and blood culture, medical intervention, and antibiotic prescriptions while in the PED. No significant differences were observed for rates of chest radiographs, hospital admissions, or 72-hour PED return visits. CONCLUSIONS: Higher rates of laboratory testing and interventions were observed in UnderI and UnI versus FI febrile patients at a PED, likely demonstrating increased clinical suspicion for invasive bacterial infection in this group despite lacking national guidelines. Given continued vaccine hesitancy, further studies are needed for guiding management of febrile UnI and UnderI children presenting for emergency care.

Naloxone-associated pulmonary edema in a 3-year-old with opioid overdose.

Background: Annually, close to 5000 children under age 6 years are treated in emergency departments or admitted for care due to opioid exposures. Naloxone is effectively used to treat opioid overdose in both children and adults. Non-cardiogenic pulmonary edema is a rare but serious adverse effect of naloxone administration that has been reported in adults. Case Report: We present the case of a 3-year-old male with suspected opioid overdose who developed acute hypoxia due to pulmonary edema after administration of naloxone following a likely prolonged downtime. Why Should an Emergency Physician Be Aware of This?: The copious fluid in the airway made for difficult intubation at a pediatric tertiary care center. Given the incidence of opioid exposures in children, clinicians should be aware of this rare, but dangerous adverse effect of naloxone and consider airway precautions and pediatric critical care availability early in the presentation.

Diabetic Ketoacidosis With Refractory Hypokalemia Leading to Cardiac Arrest.

Diabetic ketoacidosis (DKA) is known to cause total body potassium depletion, but during initial presentation, very few patients are hypokalemic, and even fewer patients experience clinical effects. As the correction of acidosis and insulin drive potassium intracellularly, measured serum potassium levels decrease and require repletion. This phenomenon is well described, and severe hypokalemia necessitates delaying insulin therapy. Less well described is the kaliuretic nature of treatments of cerebral edema. We present a case of an adolescent male with new-onset type 2 diabetes who presented in DKA with signs of cerebral edema, hyperosmolarity, and hypokalemia. As insulin and cerebral edema therapy were initiated, his hypokalemia worsened despite significant IV repletion, eventually leading to ventricular tachycardia and cardiac arrest. Over the following 36 hours, the patient received >590 milliequivalents (mEq) of potassium. He was discharged home 12 days after admission without sequelae of his cardiac arrest.