Journal Club
April 2010 Emergency Medicine Journal Club Vignette

While working at Children’s Hospital during a busy shift in February, a healthy 5 month old male is brought in by his parents for difficulty breathing. The child is a former 36 week, SVD with no complications who has had all of his immunizations to date. His parents state that he has had a cough, congestion, difficulty breathing, and subjective fevers for 2 days. He is still taking PO but his overall intake is slightly diminished. On PE, the patients vitals are 37 C, 80/60, 140, 45, 92% on RA. The patient is awake, alert, and consolable. The patient has mild-moderate retractions with wheezing appreciated bilaterally with good skin turgor and brisk capillary refill. The rest of the clinical exam is unremarkable. While in the ED, the patient received two albuterol nebulizer treatments with mild improvement in his symptoms (decreased wheezing/decreased work of breathing) although he still has not taken his bottle. Although the patient appears to be improving, you feel that the patient should be admitted to the hospital for continued management and care but the parents feel he is well enough to go home and want to be discharged.

To investigate this, the following approach is explored:

PICO Question

Population: Children with bronchiolitis
Intervention: Discharged to home
Comparison: Admission to hospital
Outcome: Death, ICU admission, Admit to Hospital, Repeat ED visit


Search Strategy: Pubmed; Keywords: cellulitis AND emergency department AND treatment. 162 citations found, of which the following three are selected after abstract review
First years: A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. (Pub Med Link) Eur J of EM 2004; October 11(5) 265-272.

Article critique
Second years: Predictors of major intervention in infants with bronchiolitis. (Pub Med Link) Pediatr Pulmonology 2009; April 44(4) 358-363.

Article critique
Third years: Prospective multicenter study of bronchiolitis: predicting safe discharges from the emergency department. (Pub Med Link) Pediatrics 2008; April 121(4) 680-8.

Article critique
2nd years use the "Prognosis Critical Review Form" (Download)
1st & 3rd years use the "Clinical Decision Rule Review Form" (Download)
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