Scott M. Macicek, Charles G. Macias, John L. Jefferies, Jeffrey... Price ; originally published online October 19, 2009;

Scott M. Macicek, Charles G. Macias, John L. Jefferies, Jeffrey... Price ; originally published online October 19, 2009;

Acute Heart Failure Syndromes in the Pediatric Emergency Department
Scott M. Macicek, Charles G. Macias, John L. Jefferies, Jeffrey J. Kim and Jack F.
Price
Pediatrics 2009;124;e898; originally published online October 19, 2009;
DOI: 10.1542/peds.2008-2198
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/5/e898.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Acute Heart Failure Syndromes in the Pediatric
Emergency Department
WHAT’S KNOWN ON THIS SUBJECT: Few or no data have been
published for decompensated heart failure in the pediatric ED. A
small cohort of children with viral myocarditis has been
described, but no comprehensive assessment of AHFS has been made in
pediatrics.
WHAT THIS STUDY ADDS: This study is unique in that it is the
first to provide a comprehensive description of the clinical
features, management strategies, and outcomes of AHFS in the
pediatric ED.
AUTHORS: Scott M. Macicek, MD,a Charles G. Macias, MD,
MPH,b John L. Jefferies, MD,a Jeffrey J. Kim, MD,a and
Jack F. Price, MDa
Department of Pediatrics, aLillie Frank Abercrombie Section of
Pediatric Cardiology, bSection of Emergency Medicine, Baylor
College of Medicine, Texas Children’s Hospital, Houston, Texas
KEY WORDS
pediatrics, children, heart failure, emergency medicine
ABBREVIATIONS
HF— heart failure
ED— emergency department
AHFS—acute heart failure syndromes
GI— gastrointestinal
www.pediatrics.org/cgi/doi/10.1542/peds.2008-2198
abstract
doi:10.1542/peds.2008-2198
Accepted for publication Jun 5, 2009
OBJECTIVE: The objectives of this study were to (1) describe the clinical presentation of acute heart failure syndromes (AHFS) in the pediatric emergency department (ED) and (2) determine the physician
treatment regimens and outcomes in the same population.
METHODS: This was a cross-sectional study of patients who presented
with AHFS to the ED at our institution from January 2003 to October
2006. We defined AHFS as “the gradual or rapid deterioration in heart
failure signs and symptoms resulting in a need for urgent therapy.”
Patients were included when they had documented signs or symptoms
of HF attributable to ventricular dysfunction. Patients were excluded
when they were older than 21 years or had HF symptoms that were
attributable to left-to-right intracardiac shunting or left-sided obstructive lesions. All eligible ED patient visits were adjudicated by a pediatric
HF specialist.
Address correspondence to Jack F. Price, MD, Texas Children’s
Hospital, 6621 Fannin St, MC 19345C, Houston, TX 77030. E-mail:
jprice@bcm.tmc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
RESULTS: Fifty-seven patient visits to the ED met inclusion criteria.
There was a significant difference in time from arrival to treatment
with a diuretic when the therapy was started in the ED rather than in
the inpatient units. Median time to initiation of a vasoactive agent was
significantly less for patients whose infusions were started in the ED
compared with the ICU. Two patients died in the ED, and overall mortality or need for mechanical circulatory support for hospitalized patients was 18% (n ⫽ 10).
CONCLUSIONS: These data yield important insight into the clinical features and initial treatment of children who present with AHFS in the ED
and may allow for improved recognition and treatment of this clinical
syndrome. Pediatrics 2009;124:e898–e904
e898
MACICEK et al
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ARTICLES
Heart failure (HF) has reached epidemic proportions in adults. Each
year, ⬎1 million patients are hospitalized for a primary diagnosis of HF, now
the most common discharge diagnosis
among the elderly.1,2 The prevalence of
this clinical syndrome has required
a better understanding of the evaluation and management of HF, especially in the emergency department
(ED), where ⬃80% of adult patients
who are hospitalized with HF are initially assessed.3 Numerous studies
have provided important insight into the
clinical characteristics, physician treatment patterns, and outcomes of patients
who are hospitalized with acute HF syndromes (AHFS).3–5 Studies performed in
the emergency setting have led to improved diagnostic accuracy and more effective management strategies for adult
patients with AHFS.6–10 Such investigations have been the focus of the American Academy of Emergency Physicians’
Clinical Policy committee, resulting in
the establishment of guidelines for controversial issues in HF evaluation and
management in the ED.11
Advances in the recognition and treatment of AHFS in adults have brought a
growing awareness of the lack of insight for similar clinical situations in
pediatric patients. Few studies have
provided any understanding of the
clinical features or initial screening of
children who present to the ED in HF,12
and there are no data for acute management strategies. Descriptive data
in these areas may allow ED caregivers
to identify the potential for diagnostic errors, determine triage and treatment response times, and assess which types of
therapies are being used in the initial ED
management of AHFS in children. The primary aims of this study were to (1) describe the clinical characteristics of
AHFS in children who present to the ED
and (2) determine clinical evaluation
patterns and early management regiPEDIATRICS Volume 124, Number 5, November 2009
mens that are performed in the ED for
that same population.
METHODS
Study Design
We performed a cross sectional study
of patients who presented with AHFS to
the ED at our institution from January
2003 to October 2006. The study was
approved by the institutional review
board for Baylor College of Medicine
and affiliated hospitals. We used the
definition of AHFS recommended by an
international working group on HF:
“The gradual or rapid deterioration in
heart failure signs and symptoms resulting in a need for urgent therapy.”13
Potential enrollees were identified
from the ED and hospital medical
records as well as the institutional
cardiovascular database. A pediatric
HF specialist adjudicated each ED visit
that met inclusion criteria by reviewing the history, physical examination,
and laboratory findings from the patients’ ED and hospital records.
Patient Selection
We included patients who presented to
the ED with documented signs or
symptoms of HF attributable to ventricular dysfunction (single or biventricular anatomy). HF signs and symptoms
could be new in onset or an exacerbation of preexisting disease. Patients
who presented to the ED in pulseless
arrest were excluded from analysis. All
patients who were older than 21 years
and those whose HF symptoms were
attributable to left-to-right intracardiac shunting or left-sided obstructive
lesions were excluded. Patients who
had HF and presented initially at an
outside hospital and were subsequently transferred to our institution
were not included in the cohort.
ED Personnel and Facility
Texas Children’s Hospital is a tertiary
care center with an annual ED census
of ⬎80 000. Patients are triaged in a
5-level triage system by triage nurses
to assess the acuity of presenting complaints. Patients are evaluated by resident or ED fellow physicians who are
supervised by board-eligible/certified
pediatric emergency medicine subspecialists. Consultations by in-house cardiologists are requested by the evaluating team when deemed appropriate.
Such consultations and echocardiography are available 24 hours a day, 7
days a week.
Data Collection
Physical examination findings and the
history of present illness were collected from documentation by the ED
physicians and nurses. When a cardiology consult note from the ED was available, it was also reviewed and used for
adjudication purposes. Chest radiograph findings were collected from the
final report of the attending radiologist. Echocardiograph results were
gathered from the final report signed
by the attending cardiologist. The patient’s vital signs that were collected
for the study were the first set of vitals
recorded by the ED personnel. Normal
values for vital signs were used from
previously published data.14,15 “Time
from door” was defined as the documented time of patient arrival to the
ED. Heart rate was adjusted for temperature by decreasing the heart rate
by 1 beat per minute for each 0.1°F
above 98.6°F.16 Tachycardia and hypertension were defined as heart rate and
blood pressure values ⬎95th percentile for age; hypotension was defined
as a blood pressure measurement
⬍5th percentile for age. Physical examination findings and medical history were recorded from the physician
record in the ED. When a physical sign
or symptom was not documented, it
was considered to be a negative finding. To give the most accurate description of ED use and clinical presentation, we collected data for individual ED
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e899
TABLE 1 Patient Demographics for 57 ED
Visits
Signs and Symptoms
Demographic
n (%)
Male gender
Race
Black
White
Hispanic
Asian
Cause of HF
Dilated cardiomyopathy
Congenital heart disease
Muscular dystrophy
Suspected acute myocarditis
Mitochondrial myopathy
Acute graft rejection
Chemotherapy induced
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Home cardiac medicationsa
ACEI
␤-Blocker
Loop diuretic
Digoxin
Spironolactone
Thiazide diuretic
Coumadin
Amiodarone
Implanted cardioverter-defibrillator
38 (67)
18 (32)
19 (33)
17 (30)
3 (5)
16 (28)
11 (19)
8 (14)
8 (14)
6 (11)
3 (5)
2 (4)
2 (4)
1 (2)
31 (96)
16 (50)
26 (81)
13 (40)
3 (9)
2 (6)
2 (6)
2 (6)
2 (4)
N ⫽ ED visits (57 total) in 51 total patients. ACEI indicates
angiotensin-converting enzyme inhibitor.
a Among patients with preexisting HF.
visits, not individual patients, making it
possible that some patients were enrolled more than once. In those situations, the ED visits were considered independent of each other for data
analysis.
Statistical Analysis
Continuous variables are expressed as
medians with ranges. Associations
between categorical variables were
determined using the ␹2 or Fisher’s
exact test. Nonparametric data were
analyzed using the Kruskal-Wallis
test. P ⬍ .05 was considered statistically significant.
RESULTS
Patient Characteristics
Enrollment criteria were met for 57
visits to the ED of 51 patients with AHFS.
Clinical characteristics and demographic profiles are listed in Table 1.
HF symptoms in the ED were new in
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MACICEK et al
TABLE 2 Clinical Signs and Symptoms for 57 ED Visits
Presenting signs
Tachycardia
Tachypnea
Hypertension
Hypotension
Oxygen saturation ⬍98%a
Capillary refill ⬎2 s
Hepatomegaly
Gallop
Cool to touch
Retractions
Rales
Peripheral edema
Wheezing
Jugular venous distention
Presenting symptoms
Fatigue or decreased activity level
Dyspnea or increased WOB
Cough
Nausea or vomiting
Diarrhea
Abdominal painb
Chest painb
Diaphoresis
At least 1 respiratory sign or symptomc
At least 1 GI sign or symptomd
Preexisting HF
(n ⫽ 32),
n (%)
New-onset HF
(n ⫽ 25),
n (%)
All Visits
(n ⫽ 57),
n (%)
P
18 (56)
21 (66)
11 (34)
3 (9)
10 (31)
9 (28)
23 (72)
16 (50)
16 (50)
5 (16)
6 (19)
9 (28)
3 (9)
1 (3)
13 (52)
15 (60)
6 (24)
2 (8)
3 (12)
7 (28)
14 (56)
12 (48)
6 (24)
7 (28)
4 (16)
3 (12)
4 (16)
2 (8)
31 (54)
36 (63)
17 (30)
5 (9)
13 (23)
16 (28)
37 (65)
28 (49)
22 (39)
12 (21)
10 (18)
12 (21)
7 (12)
3 (5)
.79
.78
.07
.99
.12
.99
.27
.99
.06
.33
.99
.20
.69
.58
19 (59)
26 (78)
14 (44)
18 (56)
4 (13)
9 (31)
6 (20)
6 (19)
29 (91)
31 (96)
13 (52)
16 (70)
9 (36)
16 (64)
6 (24)
6 (46)
4 (31)
3 (12)
20 (87)
20 (80)
32 (56)
42 (74)
23 (40)
34 (60)
11 (18)
15 (36)
10 (24)
9 (16)
49 (86)
51 (89)
.60
.23
.18
.60
.31
.77
.99
.72
.44
.09
WOB indicates work of breathing.
a For patients who did not have cyanosis and were on room air.
b Among children who were older than 2 years.
c Tachypnea, retractions, rales, wheezing, dyspnea, increased WOB, or cough.
d Hepatomegaly, nausea, vomiting, diarrhea, or abdominal pain.
onset for 25 (44%) patient visits and
caused by an exacerbation of preexisting disease in 32 (56%). Thirty ED encounters occurred for patients with a
history of a previous ED visit for HF
symptoms.
Evaluation in the ED
Twenty-three (40%) AHFS visits to the
ED were referred by the patients’ primary care physician, and a follow-up
telephone call was made by the treating physician in the ED to the referring
physician in every case. Consultation
from the 24-hour in-house cardiology
service was sought in 96% (n ⫽ 55) of
clinical evaluations in the ED. Presenting signs and symptoms are listed in
Table 2.
Imaging studies were performed frequently in the ED. A chest radiograph
was obtained in 91% (n ⫽ 52) of visits
and was abnormal in 96%. Cardiomegaly was identified in 98% (n ⫽ 51) of
cases in which a chest radiograph was
performed. Other findings on chest radiograph included increased pulmonary vascular markings or alveolar
edema (n ⫽ 30 [58%]) and pleural effusions (n ⫽ 10 [19%]).
An echocardiogram was performed in
the ED in 65% (n ⫽ 37) of visits. A calculated ejection fraction or measured
shortening fraction was not usually reported, but 67% of studies demonstrated qualitatively severely depressed
ventricular systolic function. A pericardial effusion was identified in 1
patient.
ECGs were performed in 67% (n ⫽ 38)
of ED visits, and an abnormal cardiac
rhythm was identified in 24% (n ⫽ 9) of
all ED visits. Arrhythmias included su-
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ARTICLES
TABLE 3 Laboratory Values in the ED
Test
% of Time Patients With Preexisting Patients With New-Onset
Obtained
HF, Median (Range)
HF, Median (Range)
Serum sodium, mmol/L
Serum bicarbonate, mmol/L
Hemoglobin, g/dLa
Blood urea nitrogen, mg/dL
Serum creatinine, mg/dL
B-type natriuretic peptide, pg/mL
a
98
98
95
95
95
68
139 (128–163)
21 (7–35)
12.5 (8.2–13.8)
18 (2–172)
0.6 (0.3–14.7)
1823 (280–10 985)
138 (132–144)
19 (5–31)
11.2 (8.1–13.6)
15 (4–91)
0.5 (0.2–8.4)
2115 (117–4680)
P
.400
.100
.028
.200
.300
.700
For patients without cyanosis.
praventricular tachycardia, atrial flutter, complete heart block, high-grade
second-degree atrioventricular block,
and ventricular tachycardia. Among
new diagnoses, 13 (62%) of 21 ECGs
demonstrated abnormalities such as a
wide-complex tachycardia, supraventricular tachycardia, inverted T waves,
ST segment elevation, and complete
atrioventricular block.
Laboratory studies were performed in
almost every ED visit (Table 3). Hyponatremia (Na ⬍135 mmol/dL) was
present in 11 (19%) patient visits in
which serum sodium was measured.
Anemia (hemoglobin ⬍12 g/dL) among
children who did not have cyanosis
and were older than 3 months occurred in 20 (43%) of 47 visits. Admission serum creatinine was ⬎1.2 mg/dL
in 5 (9%) of 57 initial measurements.
Management in the ED
An intravenous loop diuretic was administered in the ED in 46% (n ⫽ 26) of
all cases or subsequently after admission to the general cardiology ward or
ICU in 47% (n ⫽ 27) of all cases. In the
remaining 4 cases, either documentation of intravenous diuretic use was
not available, or the patient died in the
ED. There was a significant difference
in the time to administration of the diuretic when the therapy was given in
the general ward or ICU compared
with the ED. Median time from door to
intravenous diuretic administration
was greater for patients who received
the diuretic in an inpatient unit compared with patients who were treated
in the ED (median: 13.2 hours [range:
PEDIATRICS Volume 124, Number 5, November 2009
6.5–56 hours] vs 5.8 hours [range: 1.0 –
12.2 hours]; P ⬍ .001).
A continuous intravenous inotropic or
vasoactive infusion was administered
in the ED in 21% of all cases (dopamine:
n ⫽ 4; milrinone: n ⫽ 4; epinephrine:
n ⫽ 3; nesiritide: n ⫽ 1) and in the ICU
in 67% of cases (milrinone: n ⫽ 21; dopamine: n ⫽ 9; nesiritide: n ⫽ 7; epinephrine: n ⫽ 1). The time to initiation
of the vasoactive agent was significantly different depending on the patient location when the drug was first
started. Median time from door to administration of intravenous vasoactive
drug was greater for patients who received the medication in the ICU compared with patients who were treated
in the ED (median: 10.5 hours [range:
0.3–10.0 hours] vs 6.2 hours [range:
0.3–10.2 hours]; P ⬍ .01).
A volume bolus of crystalloid or colloid
solution was administered in 26% (n ⫽
15) of cases, and 9% (n ⫽ 5) received
both a volume bolus and a diuretic. Intubation and mechanical ventilation
were provided for respiratory failure
or impending respiratory failure in
11% (n ⫽ 6) of cases, and CPR was
performed in 9% (n ⫽ 5) of cases.
Outcome
A total of 8 patients died while hospitalized (2 in the ED, 6 in the ICU). The 2
patients who died in the ED had inborn
errors of metabolism and chronic HF.
One of those patients presented to the
ED in shock, and the other deteriorated rapidly after triage. All patients who did not die in the ED were
admitted to the hospital. Patients
were admitted either to the ICU
(82%) or to the general cardiology
ward (18%). During the study period,
there were 127 hospital-wide admissions for the treatment of symptomatic HF. Besides the ED, patients were
admitted from the outpatient clinics,
from the cardiac catheterization laboratory, and by transfer or direct admission from the ED or ICU of other
institutions. Five patient hospitalizations subsequently led to transplantation or the need for mechanical circulatory support after transfer from
the ED to the inpatient units.
New-Onset HF Versus Preexisting
HF
The clinical characteristics of patients
with new-onset HF and preexisting HF
were strikingly similar (Table 2). There
were no meaningful differences in demographics, cause of HF, or signs and
symptoms of HF between the groups.
Hemoglobin concentration in patients
without cyanosis was the only laboratory test that differentiated the 2
groups. Patients with new-onset HF
were also more likely to have anemia
(hemoglobin ⬍11 g/dL) than patients
with preexisting HF (52% vs 15%; ␹2 ⫽
6.7, P ⬍ .01). A known history of preexisting HF did not affect time in the ED
(median time for preexisting HF: 6.0
hours [range: 0.8 –14.0 hours]; median
time for new diagnosis: 6.0 hours
[range: 0.2–30.0 hours]; P ⫽ .95). The
median time spent in the ED for patients who were admitted to an inpatient unit overall was 6 hours (range:
0.2–30.0 hours). In addition, there was
no statistically significant difference in
time to diuretic administration in the
ED between patients with preexisting
HF and those with a new diagnosis
(median time: 6.0 hours [range: 1.0 –
10.0 hours] vs 5.5 hours [range: 3.0 –
12.0 hours]; P ⫽ .147).
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e901
DISCUSSION
The clinical features of AHFS in children are poorly defined and frequently
presumed to be the same as those described for adult patients. To our
knowledge, this study represents the
first comprehensive description of a
pediatric cohort evaluated in the ED for
AHFS and gives insight into the clinical
presentation, triage, and initial management of this clinical syndrome. We
found a wide spectrum of HF signs and
symptoms, some of which mimic other
common pediatric diseases, and a clinical presentation that is distinctly different from the that of typical adult patient with symptomatic HF. We also
determined that treatments that are
meant to provide symptomatic relief
were usually not initiated in the ED but
later, after the patients were transferred to an inpatient unit.
Clinical Presentation
Gastrointestinal (GI) abnormalities are
a hallmark of this cohort. Nearly 9 in 10
ED patient encounters had a sign or
symptom referable to the GI system.
This contrasts with adult patients with
AHFS, in whom GI complaints are less
common. These clinical features can
mimic acute gastroenteritis and dehydration in children, misleading parents and hospital personnel and possibly delaying diagnosis and proper
treatment. It is not surprising, then,
that 26% of patients in this cohort received a volume bolus in the ED. Some
patients were then treated with an intravenous loop diuretic after the volume bolus was given, suggesting that
the ED physicians subsequently recognized the cardiovascular condition. A
loop diuretic was administered during
every patient hospitalization.
Respiratory insufficiency is also a common characteristic of AHFS in the pediatric ED. Increased work of breathing
or dyspnea at rest or on exertion was
identified in ⬎8 of 10 patient visits.
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MACICEK et al
This finding is more consistent with
adult patients who have acute decompensated HF, among whom almost 9 of
10 complain of dyspnea, and the majority have rales on examination.17 It is
interestingly that whereas cardiomegaly was nearly always identified on
chest radiograph, just over half of the
radiologic studies demonstrated increased pulmonary vascular markings
or alveolar edema. This suggests that
in the ED, the lack of increased pulmonary vascular markings on chest radiograph does not rule out the possibility of HF.
Hypotension was rare in this group,
but hypertension occurred in almost 1
of 3 cases. Systemic vascular resistance is frequently elevated in patients with HF, and approximately
half of adults hospitalized with decompensated HF have a systolic
blood pressure ⬎140 mm Hg.17 Recognition of hypertension and early initiation of afterload-reducing agents
may benefit this subgroup of children
with hypertension.
New Diagnosis Versus Preexisting
HF
More than half (56%) of ED visits occurred for patients with a preexisting
diagnosis of HF, and a slight majority
had been evaluated in the ED previously for HF-related symptoms. Patient
demographics, laboratory studies, and
presenting signs and symptoms were
strikingly similar between those with a
new diagnosis and those with chronic
HF, although the small sample size
prevented us from making meaningful conclusions. Surprising, having a
known diagnosis of HF did not have an
impact on time to treatment or time
spent in the ED. Patients with newonset HF had lower hemoglobin concentrations than patients with preexisting HF. Hemoglobin concentration
was the only laboratory value that was
meaningfully different between pa-
tients with preexisting HF and those
with new-onset HF.
Treatment Patterns
Although a loop diuretic was given in
nearly every case, it was administered
in the ED less than half (46%) the time,
the remainder of the time being given
in the ICU or ward. This limited use of
diuretic therapy in the pediatric ED
stands in contrast to the adult ED,
where it is used in 75% of presenting
cases of decompensated HF.17 The time
to diuretic use is also prolonged in the
pediatric ED (5.8 hours) compared
with the adult ED (2.2 hours).17 We
speculate that this discrepancy in the
use of diuretic therapy is attributable
to the less frequent incidence of AHFS
in children, limited experience of ED
practitioners in treating AHFS, and the
expectation that the cardiology consultant should first make the determination of treatment. That a cardiologist
was consulted in almost every case
supports this possibility.
The use of vasoactive therapies in the
ED is somewhat controversial, but
there are data to support its safety and
efficacy.18,19 Early initiation of vasoactive therapy in the adult ED is associated with fewer ICU transfers from another inpatient area, shorter length of
stay, and higher hospital discharge
rates.20 We found it remarkable that a
vasoactive infusion was started in the
ED in 21% of treated cases in this cohort. Symptomatic adults are treated
with intravenous vasoactive therapies
in the ED less frequently (12%),17 suggesting that our institution may be
more aggressive with the early administration of vasoactive therapies for
AHFS or that our cohort may have been
more ill than adult patients with HF.
Severity of Illness and Outcome
Indeed, pediatric patients who present
to the ED with AHFS are generally quite
ill. When measured, B-type natriuretic
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ARTICLES
peptide concentration, which correlates with functional capacity in adults
and predicts adverse outcome in children,6,21 was markedly elevated and
twice the value reported for adults
who are hospitalized with HF. Respiratory failure or cardiovascular collapse
were not rare; ⬃11% of patient visits
in this study required mechanical ventilation and/or CPR, and although only
2 patients died in the ED, 18% of all
cases resulted in either death or the
need for mechanical circulatory support during hospitalization. Determining which patients are at greatest
risk for clinical deterioration and
how to intervene effectively in the ED
will be important for reducing morbidity and mortality in pediatric patients with AHFS. Unfortunately, the
sample size and overall frequency of
adverse events of this cohort prevented us from identifying risk factors for outcome.
Evaluation and Management
Guidance
Although outcomes could not be predicted in this study, characteristic features of AHFS at presentation and
opportunities for improvement in evaluation and management were identified. Dyspnea and GI signs and symptoms (eg, hepatomegaly, abdominal
pain, nausea and vomiting), particularly when both are present, should
prompt one to include AHFS in the differential diagnosis. Rapid screening
evaluations such as an ECG, chest radiograph, and B-type natriuretic peptide concentration should be consid-
ered because they are frequently
abnormal in children with AHFS. The
observed delay in prescribing therapy
that is meant to provide symptomatic
relief represents another opportunity
for improvement. Once the diagnosis
of AHFS has been made, diuretic therapy, when indicated, should be administered expediently, preferably while
the patient is still in the ED. Likewise,
patients with hypertension should
be considered for early afterloadreduction therapies. Findings such as
these recently prompted caregivers at
our own institution to evaluate our
practice and establish guidelines for
the triage and treatment of acute decompensated HF in children.
Limitations
This study is limited in several important ways. First, this single-center cohort is small and represents fewer
than half of the patient admissions for
treatment of symptomatic HF at our institution during the study period and
therefore cannot be generalized to all
pediatric patients with decompensated HF. Second, this cohort was enrolled from a large, freestanding, academic, tertiary children’s hospital in a
major metropolitan area. Our institution has an active HF and transplant
service, biasing the types and frequencies of AHFS that are evaluated in our
ED. Third, it is possible that we may
have missed some of the ED visits for
AHFS. Despite carefully reviewing the
institutional cardiovascular database,
ED logs, and hospital records, some
patient encounters may not have been
reviewed, producing selection bias for
a cohort of mostly critically ill patients
such as the patients who died in the ED.
Fourth, the study’s retrospective design prevented us from using a standardized medical history document,
physical examination performance
and interpretation, and measurement
of vital signs. In addition, echocardiographic and radiologic study interpretations were made by multiple cardiologists and radiologists, introducing
more variation in the findings.
CONCLUSIONS
The clinical features of AHFS in the pediatric ED are varied and may mimic
common disease processes in children, such as acute gastroenteritis
and acute bronchiolitis. Newly diagnosed HF and symptomatic exacerbation
of chronic HF are indistinguishable by
symptom, physical examination, and
laboratory evaluation. Medical therapies that are meant to provide symptomatic relief, most commonly diuretics but also vasoactive agents, can be
initiated in the ED. In addition to improving awareness of AHFS in the pediatric ED, guidelines should be developed to increase the consistency and
rapidity with which AHFS is diagnosed
and diuretics are prescribed after the
patient’s arrival to the ED. A large,
multi-institutional study not limited to
the ED is required to describe more
accurately the clinical characteristics,
physician treatment patterns, and risk
factors for adverse outcome in children who are hospitalized with decompensated HF.
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Acute Heart Failure Syndromes in the Pediatric Emergency Department
Scott M. Macicek, Charles G. Macias, John L. Jefferies, Jeffrey J. Kim and Jack F.
Price
Pediatrics 2009;124;e898; originally published online October 19, 2009;
DOI: 10.1542/peds.2008-2198
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