RESUMO
PRIMARY OBJECTIVE: To examine the frequency of acute mild traumatic brain injury (mTBI) symptoms in children using a concussion symptom inventory and to identify which symptoms are most useful in identifying mTBI. It was hypothesized that symptoms associated with mTBI are more common in children with head injury than orthopaedic injury and certain symptoms are more useful than others in identifying mTBI. RESEARCH DESIGN: Prospective case-control study conducted in a paediatric trauma centre emergency department. METHODS AND PROCEDURES: Children of 6-18 years old with head injury or a minor extremity injury were enrolled. Symptoms were assessed using a graded symptom checklist. Symptom frequency was compared using a chi-square test. The association between individual symptoms with AMS was evaluated with logistic regression analysis. MAIN OUTCOMES AND RESULTS: Children with head injury displayed more frequent symptoms than controls. Head-injured cases with altered mental status (AMS) demonstrated the most frequent and severe symptoms (median symptom scores: control = 1, cases without AMS = 5, cases with AMS = 10; p < 0.001). Headache, nausea, dizziness, blurred/double vision and not feeling 'sharp' were associated with AMS. CONCLUSIONS: Symptoms associated with mTBI are more frequent in children with head injury. AMS magnifies this effect. A symptom inventory is integral to the evaluation of mTBI in children; a smaller set of dichotomized symptoms may be as useful as and more easily administered than lengthier symptom scales.
Assuntos
Concussão Encefálica/fisiopatologia , Traumatismos Craniocerebrais/fisiopatologia , Síndrome Pós-Concussão/fisiopatologia , Adolescente , Concussão Encefálica/complicações , Concussão Encefálica/diagnóstico , Estudos de Casos e Controles , Criança , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/diagnóstico , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Síndrome Pós-Concussão/diagnóstico , Síndrome Pós-Concussão/etiologia , Prevalência , Estudos Prospectivos , Fatores de Tempo , Centros de TraumatologiaRESUMO
STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.
Assuntos
Anestésicos Dissociativos/efeitos adversos , Serviço Hospitalar de Emergência , Ketamina/efeitos adversos , Agitação Psicomotora/etiologia , Vômito/induzido quimicamente , Fatores Etários , Período de Recuperação da Anestesia , Anestésicos Dissociativos/administração & dosagem , Benzodiazepinas/administração & dosagem , Criança , Pré-Escolar , Antagonistas Colinérgicos/administração & dosagem , Feminino , Humanos , Lactente , Injeções Intramusculares , Injeções Intravenosas , Ketamina/administração & dosagem , Masculino , Fatores de RiscoRESUMO
STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
Assuntos
Anestésicos Dissociativos/administração & dosagem , Anestésicos Dissociativos/efeitos adversos , Serviço Hospitalar de Emergência , Ketamina/efeitos adversos , Sistema Respiratório/efeitos dos fármacos , Adolescente , Fatores Etários , Benzodiazepinas/administração & dosagem , Criança , Pré-Escolar , Antagonistas Colinérgicos/administração & dosagem , Tratamento de Emergência , Feminino , Humanos , Incidência , Lactente , Infusões Intravenosas , Ketamina/administração & dosagem , Masculino , Valor Preditivo dos Testes , Fatores de RiscoRESUMO
STUDY OBJECTIVE: We investigate the effect of ondansetron on the incidence of vomiting in children who receive intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED). METHODS: In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IV ketamine (1 mg/kg) for ED procedures were randomized to receive either IV ondansetron (0.15 mg/kg; maximum 4 mg) or identical placebo. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction. RESULTS: One hundred twenty-seven children were randomized to placebo and 128 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was less common with ondansetron: 6 of 128 (4.7%) versus 16 of 127 (12.6%), P=.02, difference 7.9% (95% confidence interval 1.1% to 14.7%), number needed to treat 13. Follow-up was successful in 82.7%, with vomiting in the ED or after discharge less frequent with ondansetron: 10 of 128 (7.8%) versus 24 of 127 (18.9%), P=.01, difference 11.1% (95% confidence interval 2.7% to 19.5%), number needed to treat 9. ED length of stay and parental satisfaction were similar between groups. CONCLUSION: IV ondansetron significantly reduces the incidence of vomiting associated with IV ketamine procedural sedation in children.
Assuntos
Anestésicos Dissociativos/efeitos adversos , Antieméticos/uso terapêutico , Ketamina/efeitos adversos , Ondansetron/uso terapêutico , Vômito/tratamento farmacológico , Adolescente , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Método Duplo-Cego , Serviço Hospitalar de Emergência , Feminino , Humanos , Incidência , Lactente , Masculino , Resultado do Tratamento , Vômito/epidemiologia , Vômito/etiologiaRESUMO
STUDY OBJECTIVE: We determine whether a fascia iliaca compartment nerve block can provide superior pain management compared with intravenous morphine sulfate for the initial pain management of femur fracture patients presenting to a pediatric emergency department. The primary outcome measured is pain scores; a difference of 15% in scores assessed at 30 minutes from the study's baseline pain management is considered clinically meaningful. Secondary outcomes include the duration of analgesia, the need for additional medications, adverse events, nerve block complications, and satisfaction scores. METHODS: This was a prospective, randomized, unblinded, controlled trial conducted on children aged 15 months to 18 years with acute femur fractures, presenting to a free-standing, tertiary care children's hospital. Patients were randomized to receive intravenous morphine sulfate or a fascia iliaca compartment nerve block using ropivacaine (Naropin). Pain scores (Children's Hospital of Eastern Ontario Pain Scale [CHEOPS]; Face, Legs, Activity, Cry and Consolability Pain Scale; Faces Pain Scale) were recorded at initial analgesic administration (baseline), at 5, 10, 15, 30, and 60 minutes, and then hourly up to 6 hours from baseline by trained nursing observers and research assistants. RESULTS: Fifty-five patients, 26 in the fascia iliaca compartment nerve block group and 29 in the morphine sulfate group, ranged in age from 16 months to 15 years (median 5.7 years). Baseline mean CHEOPS scores were similar: 9.4 fascia iliaca compartment nerve block and 9.5 morphine sulfate. Mean CHEOPS scores at 30 minutes after initial treatment were 5.87 for fascia iliaca compartment nerve block and 7.54 for morphine sulfate, with a difference of 1.67, which corresponds to an 18% (95% confidence interval [CI] 8% to 27%) difference in pain reduction between the 2 groups, according to the average baseline score of 9.45. Similar lower pain scores were observed in the fascia iliaca compartment nerve block group as early as 10 minutes from baseline and throughout the 6-hour duration of the study. In comparing the entire 6-hour CHEOPS pain scores, patients who received a fascia iliaca compartment nerve block showed lower scores by approximately 15% (95% CI 6% to 24%) compared to patients who received morphine sulfate. Median duration of analgesia was longer in the fascia iliaca compartment nerve block group compared with that in the morphine sulfate group (313 minutes [95% CI 154 to 360 minutes] versus 60 minutes [95% CI 10 to 255 minutes]). Fewer additional medications were given to patients who received the fascia iliaca compartment nerve block. No complications from the nerve block occurred. Satisfaction scores were higher with the fascia iliaca compartment nerve block among the medical staff. CONCLUSION: Fascia iliaca compartment nerve block provided clinically superior pain management compared with intravenous morphine sulfate at 30 minutes from baseline and throughout the initial 6 hours of medical treatment of children 16 months to 15 years who had isolated acute femur fractures. The results of this study, however, may be inflated by the nonblinding of the pain observers. Despite this potential bias, the fascia iliaca compartment nerve block should be considered as a valuable procedure in managing the pain commonly observed in these injured children.
Assuntos
Analgésicos Opioides/administração & dosagem , Fraturas do Fêmur/terapia , Morfina/administração & dosagem , Bloqueio Nervoso , Manejo da Dor , Adolescente , Amidas , Analgésicos Opioides/uso terapêutico , Anestésicos Locais , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Infusões Intravenosas , Masculino , Morfina/uso terapêutico , Bloqueio Nervoso/métodos , Dor/etiologia , Medição da Dor , Satisfação do Paciente , Estudos Prospectivos , RopivacainaRESUMO
STUDY OBJECTIVE: We compare adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED). METHODS: Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children's hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg i.v. or 4 mg/kg i.m. Demographics, adverse events, sedation efficacy, and length of sedation were recorded. RESULTS: Two hundred twenty-five patients were randomized (116 i.v., 109 i.m.). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 i.v. and 99 i.m. Respiratory adverse events were similar between groups (i.v. 8.3% versus i.m. 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the i.m. group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9). Using the Faces Pain Scale, patients in the i.m. group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the i.m. group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 i.m. versus 0.74 i.v.; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the i.m. group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine i.m. CONCLUSION: In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg i.m. was more effective than 1 mg/kg i.v. but demonstrated significantly longer recovery times and more vomiting.
Assuntos
Hipnóticos e Sedativos/administração & dosagem , Ketamina/administração & dosagem , Procedimentos Ortopédicos , Adolescente , Período de Recuperação da Anestesia , Criança , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Humanos , Lactente , Infusões Intravenosas , Injeções Intramusculares , Masculino , Estudos ProspectivosRESUMO
STUDY OBJECTIVE: We assess accuracy of ECG interpretation and indications for obtaining ECGs and develop a clinical classification system of ECG abnormalities. METHODS: Prospectively acquired ECG data on patients 0 to 21 years of age and presenting to our pediatric emergency department (ED) were obtained. Clinical indications were documented. The initial ECG interpretation (pediatric ED attending physician) was compared with the criterion standard (pediatric cardiologist). A blinded cardiology panel reviewed discrepancies, and a final concordance rate was determined. An ECG abnormality classification system was developed and used to categorize these abnormal ECGs. RESULTS: One thousand six hundred fifty-three ECGs from 1,501 patients, aged 2 days to 21 years (median 10.0 years), were obtained during 3.5 years. Fifty-one percent were male patients. ECG indications included chest pain (21%), seizure or syncope (18%), arrhythmias (17%), apparent life-threatening event or respiratory symptoms (16%), ingestions (10%), cardiac abnormality (10%), and miscellaneous (8%). From 1,631 ECGs, 1,160 (71%) were normal (class 0), 259 (16%) were minimally abnormal (class I), 174 (11%) were moderately abnormal (class II), and 38 (2%) were severely abnormal (class III). Kendall's tau-b test showed concordance of 0.73 (95% confidence interval 0.70 to 0.77) between pediatric ED and cardiology interpretation. The sensitivity of pediatric ED interpretation was 75%, and the specificity was 98.5%. The positive predictive value of pediatric ED interpretation was 88.3%, and the negative predictive value was 96.3%. CONCLUSION: We conclude that, overall, a high rate of concordance exists between the pediatric emergency physician's and the cardiologist's ECG interpretation. The majority of discordant ECGs are not clinically significant. However, among the clinically significant ECGs, there is a higher rate of discordance. These data suggest that review of pediatric ECGs by pediatric cardiologists may significantly reduce underdetection of clinically important ECG findings in children.
Assuntos
Competência Clínica , Eletrocardiografia , Medicina de Emergência/métodos , Serviço Hospitalar de Emergência , Cardiopatias/diagnóstico , Pediatria/métodos , Adolescente , Adulto , Cardiologia/métodos , Cardiologia/estatística & dados numéricos , Criança , Pré-Escolar , Colorado , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
STUDY OBJECTIVE: Fasting time before procedural sedation and analgesia in a pediatric emergency department (ED) was recently reported to have no association with the incidence of adverse events. This study further investigates preprocedural fasting and adverse events. METHODS: Data were analyzed from a prospectively generated database comprising consecutive sedation events from June 1996 to March 2003. Comparisons were made on the incidence of adverse events according to length of preprocedural fasting time. RESULTS: Two thousand four hundred ninety-seven patients received procedural sedation and analgesia. Four hundred twelve patients were excluded for receiving oral or intranasal drugs (n=95) or for receiving sedation for bronchoscopy by nonemergency physicians (n=317). A total of 2,085 patients received parenteral sedation by emergency physicians. Age range was 19 days to 32.1 years (median age 6.7 years); 59.9% were male patients. Adverse events observed included desaturations (169 [8.1%]), vomiting (156 [7.5%]), apnea (16 [0.8%]), and laryngospasm (3 [0.1%]). Fasting time was documented in 1,555 (74.6%) patients. Median fasting time before sedation was 5.1 hours (range 5 minutes to 32.5 hours). When the incidence of adverse events was compared among patients according to fasting time in hours (0 to 2, 2 to 4, 4 to 6, 6 to 8, >8, and not documented), no significant difference was found. No patients experienced clinically apparent aspiration. CONCLUSION: No association was found between preprocedural fasting and the incidence of adverse events occurring with procedural sedation and analgesia.
Assuntos
Analgesia/efeitos adversos , Analgesia/métodos , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Medicina de Emergência/métodos , Jejum , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Masculino , Pediatria/métodos , Transtornos Respiratórios/etiologia , Fatores de Tempo , Vômito/etiologiaRESUMO
OBJECTIVE: The Standardized Assessment of Concussion (SAC) is a validated tool for identifying the effects of mild traumatic brain injury (mTBI). Previous research focused on sport-related sideline evaluation of adolescents and adults. Our goal was to evaluate performance of the SAC among subjects with and without head injury in a pediatric emergency department (ED). METHODS: This was an observational study of children 6 to 18 years of age who presented to an ED with blunt head injury (case-patients) or minor extremity injury (controls). SAC and graded-symptom-checklist scores were compared. American Academy of Neurology concussion grades, presence of loss of consciousness and posttraumatic amnesia were also compared with SAC and graded-symptom-checklist scores among case-patients. RESULTS: Three hundred forty-eight children were enrolled. SAC scores trended lower (greater cognitive deficits) for case-patients compared with controls but did not reach significance. Graded-symptom-checklist scores were significantly higher among case-patients. Presence of altered mental status magnified this effect. There was no correlation between SAC scores and other indicators of mTBI. There was a positive correlation between graded-symptom-checklist scores and posttraumatic amnesia and American Academy of Neurology concussion grade. CONCLUSIONS: The graded symptom checklist reliably identified mTBI symptoms for all children aged 6 years and older. SAC scores tended to be lower for case-patients compared with controls but did not reach significance. Patients with altered mental status at the time of injury manifest an increased number and severity of symptoms. Additional research into strategies to identify cognitive deficits related to mTBI and classify mTBI severity in children is needed.
Assuntos
Concussão Encefálica/diagnóstico , Serviço Hospitalar de Emergência , Inquéritos e Questionários , Adolescente , Amnésia/diagnóstico , Amnésia/etiologia , Concussão Encefálica/complicações , Criança , Transtornos Cognitivos/diagnóstico , Feminino , Traumatismos Cranianos Fechados/complicações , Hospitais Pediátricos , Humanos , Masculino , Centros de Traumatologia , Inconsciência/etiologiaRESUMO
OBJECTIVES: To compare the frequency and severity of adverse events associated with parenteral drugs commonly used for procedural sedation and analgesia (PSA) in a pediatric emergency department. METHODS: A database of consecutive patients receiving parenteral PSA was prospectively generated with the intent of monitoring safety in the emergency department. Data were logged onto a dedicated sedation sheet. A retrospective analysis was performed; comparisons were made based on sedation drugs used. RESULTS: A total of 2,609 patients from June 1, 1996, to September 16, 2003, received PSA by emergency physicians. Patients who received PSA nonparenterally (n = 109) were excluded. A total of 2,500 patients (2,279, intravenous; 221, intramuscular) remained for analysis. Age range was 19 days to 32 years (median, 6.7 years). A total of 1,511 (60.4%) were male. Four major drug combinations were identified: ketamine alone (n = 1,492; 59.7%), ketamine/midazolam (n = 299; 12.0%), midazolam/fentanyl (n = 336; 13.4%), and midazolam alone (n = 260; 10.4%). A total of 113 patients (4.5%) received various other combinations of drugs. A total of 458 adverse events were observed in 426 patients (17%). Respiratory adverse events occurred as follows: ketamine alone, 91 patients (6.1%); ketamine/midazolam, 30 patients (10%); midazolam/fentanyl, 65 patients (19.3%); midazolam alone, 15 patients (5.8%). Vomiting occurred as follows: ketamine alone, 151 patients (10.1%); ketamine/midazolam, 16 patients (5.4%); midazolam/fentanyl, six patients (1.8%); midazolam alone, two patients (0.8%). CONCLUSIONS: Drug types used in pediatric PSA are associated with different adverse event profiles. Patients receiving ketamine with or without midazolam experienced fewer respiratory adverse events but more vomiting than the commonly used combination of midazolam and fentanyl. Adverse events may occur in any patient receiving parenteral PSA.
Assuntos
Analgesia/efeitos adversos , Analgesia/estatística & dados numéricos , Sedação Consciente/efeitos adversos , Sedação Consciente/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Adolescente , Adulto , Analgesia/métodos , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Doenças Cardiovasculares/induzido quimicamente , Criança , Pré-Escolar , Estudos de Coortes , Colorado , Sedação Consciente/métodos , Quimioterapia Combinada , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Lactente , Recém-Nascido , Infusões Parenterais , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Avaliação de Processos e Resultados em Cuidados de Saúde , Pediatria/instrumentação , Doenças Respiratórias/induzido quimicamente , Estudos Retrospectivos , Vômito/induzido quimicamenteAssuntos
Proteção da Criança , Desastres , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Socorro em Desastres/organização & administração , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/etiologia , Estresse PsicológicoRESUMO
BACKGROUND: The serum electrolyte panel (SEP) is a frequently ordered laboratory test, but it has unproven usefulness in the treatment of dehydrated pediatric patients. Our study purpose was to evaluate the usefulness of routinely ordering a SEP in the treatment of dehydrated pediatric patients receiving intravenous fluids (IVFs). METHODS: Children 2 months to 9 years of age who were receiving IVFs because of dehydration were prospectively studied in a pediatric emergency department (PED). Historical data, physical examination findings, degree of dehydration, and SEP results were recorded. After patient evaluation, attending physicians documented whether they would have ordered a SEP. Outcome measurements included changes in clinical management on the basis of SEP results, as well as correlations of dispositions and unscheduled return visits (URVs) with SEP results. RESULTS: A total of 182 patients were enrolled in the study. One hundred eleven patients had mild dehydration, 55 moderate dehydration, and 16 severe dehydration. Eighty-eight patients (48%; 95% confidence interval: 41-56%) had > or =1 abnormal SEP value. Clinically relevant findings included bicarbonate levels of <16 mmol/L for 28% of patients, hypoglycemia for 9.9%, hypokalemia for 6.0%, and hypernatremia for 3.0%. The attending physicians predicted that a SEP would be clinically important for 34% of all patients. There was a 58% sensitivity in detecting which children would have clinically significant SEP results. Overall, SEP results changed clinical management in 10.4% of cases. One hundred sixty-five (91%) of the patients were discharged from the PED (including 48 who were initially observed), of whom 7 (3.8%) had URVs to the PED within 72 hours and were given additional IVFs. Seventeen patients were admitted (median: 2.6 days), 2 of whom had URVs after hospital discharge for additional IVFs. CONCLUSIONS: On the basis of initial presentation, attending physicians were poor at predicting which children would have clinically significant SEP results. Low bicarbonate values were correlated with observation unit use but not with hospitalization or URVs. The observation unit provided effective care for a subset of dehydrated patients, avoiding the need for hospitalization. Obtaining a SEP can provide useful information for the treatment of some children receiving IVFs because of dehydration.