The Pediatric Needle In A Haystack Problem – Links To And Excerpts From Articles On Abnormal Pediatric Vital Signs In The ED

In this post I link to and excerpt from articles dealing with the perennial problem in pediatrics: The Pediatric Needle In A Haystack.

The Pediatric Needle In A Haystack problem is finding the occasional [even rare] pediatric patient who is seriously ill. The vast majority of ill pediatric patients visiting the doctor, urgent care, or emergency department will be carefully evaluated and found to have no evidence of serious disease.

However, what should we do with pediatric patients who appear completely well after a careful evaluation but who have abnormal vital signs in the office, urgent care center, or emergency department?

Here are two resources that address this problem:

  1. Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs [PubMed Abstract] [Full Text HTML] [Full Text PDF]. West J Emerg Med. 2017 Aug; 18(5): 878–883.
  2. Outcomes of Pediatric Patients with Tachycardia at Discharge from Core EM, October 5, 2017 by Kelsey Fawcett, MD:


Tachycardia is a very common abnormal vital sign in the Pediatric Emergency Department (ED). Tachycardia can have numerous underlying causes including less concerning clinical states such as fever, pain, and anxiety but can also be a sign of impending cardiovascular decompensation which occurs in shock, sepsis, and cardiac dysfunction.

You need to carefully review the above articles

The pediatric patients with abnormal vital signs, that were discharged and followed in the above articles, did well.

However, this was due, I think, to the fact that the clincians evaluating these pediatric patients were doing a great job of ruling out serious disease.

If the pediatric patient had had any significant abnormality on history or physical examination by the clinician, the patient would undoubtedly not have been discharged even if the vital signs were all within normal limits.

And all pediatric patients’ parents need clear instructions on when to return to the office (or ED) if the child’s condition changes or gets worse.

The Royal Children’s Hospital of Melbourne has great pediatric disease fact sheets [View By Title] [View By Category] that can be used to help parents understand when to come back to clinic or ED.

The big thing I tell all my parents when I discharge their child is, “If you think something might be going on that needs to be rechecked, don’t wait. It is not your job to prove your child is sick. It is our job to prove she’s not.”




This entry was posted in Core EM, Pediatric Emergency Medicine, Pediatric Vital Signs, Pediatrics. Bookmark the permalink.