Keywords
emergency medical services - pediatrics - otorhinolaryngologic diagnoses
Introduction
Symptoms such as fever and pain are among the most frequent complaints recorded during
emergency room (ER) pediatric patient treatment[1]. Notably, these symptoms are very common in ear, nose, and throat (ENT) pathologies[2]; large ENT emergency centers are an important part of emergency care. An estimated
25–40% of general medical practice relates to ENT problems[3]
[4].
The presence of on-call ENT specialists is uncommon in child emergency hospitals in
the state of São Paulo. For this reason, the pediatricians that are on duty are called
on to provide these services, including in some instances, evaluating otorhinolaryngology
disorders that require specialist assessment. A discrepancy was noted between pediatricians
and otorhinolaryngologists with regard to the diagnosis and treatment of upper respiratory
infections[5].
Few epidemiological studies have been conducted in pediatric emergency departments
with focus on otorhinolaryngology care. Some studies have noted frequent visits to
emergency departments that specialize in otorhinolaryngology[6]
[7]
[8]
[9]
[10], which exist only in large centers.
Hospital Santa Casa de Misericordia de Itatiba provides the only public emergency
service in the city of Itatiba; in 2011, it provided treatment to 32,901 pediatric
patients: 72.4% of the visits were through public service and only one other pediatric
service in the city offered treatment through insurance. Itatiba is located in São
Paulo, 80 km from the capital. It has a population of 101,471[11] and its human development index level is 0.828, 38th in the state. Its economy is
industrial-based[12] and is part of the Jundiaí-DRS VII region (Campinas).
The objective of this study was to detect the prevalence of otorhinolaryngologic diagnoses
in a pediatric population in a reference hospital in Itatiba City, São Paulo.
Methods
We evaluated 2,054 pediatric patients (age range, 0–12 years, 11 months) who voluntarily
sought emergency room treatment, arrived by ambulance, were transferred from other
services, were under observation, and/or had been present from the day shift (07:00
a.m. to 07:00 p.m.).
We excluded patients who voluntarily opted not to receive treatment even though a
patient chart had been prepared for them
The enrolled patients were from both the public health care system and the private
health sector.
The study was descriptive, transversal, and observational (survey). Data collection
was performed during 103 night shifts (07:00 p.m. to 07:00 a.m.) between January and
December 2011. The main diagnosis, and patient age and sex were recorded. The ethics
committee and research institution approved the study.
A single observer performed the data collection. The first 6 months of the study sessions
were shared with another attending physician, whose patients were not included in
the study. The average attendance was 13 patients per shift during the first 6 months
and 26 during the last 6 month.
Patients were divided into 2 groups based on diagnosis: Group A otorhinolaryngologic
diagnoses, and Group B included patients with diagnoses other than those included
in Group A.
Group A patients were grouped based on diagnostic hypotheses involving the ear, nose,
larynx-pharynx-mouth (LPM), nonspecific upper airway infections (UAI), or others (e.g.,
ALTE, tracheostomy management, dental avulsion, toothache, dacryocystitis, facial
herpes, or reactive lymphadenitis).
A patient was considered to have nonspecific UAI if symptoms were recent (48 hours)
and likely due to a virus, if the patient expressed vague complaints regarding the
upper airways, if the patient exhibited a low fever, and if a focus of infection was
not evident yet.
Group B patients were grouped based on diagnostic hypotheses of the gastrointestinal
tract, lower respiratory tract, urinary tract, skin and appendages, healthy patients
(eutrophic), other trauma, other diseases of the eye and appendages, diseases of the
central nervous system, and others (e.g., exogenous intoxication, undiagnosed fever,
purpura, arthralgia, suspected leptospirosis, suspected sexual abuse, hypoglycemia,
cardiopulmonary arrest reversed).
Results
Of the 2,054 admissions to the pediatric ER, 1,072 (52.2%) corresponded to Group A
and 982 (47.8%) to Group B ([Chart 1]).The sex breakdown was 51.9% male and 48.1% female.
Chart 1. Relationship between patients with ENT and non-ENT diagnoses who were treated at
the pediatric emergency room during night shifts in 2011 at Hospital Santa Casa de
Misericordia Itatiba.
With regard to age, the largest age group was patients aged under 1 year (15.3%),
followed closely by patients 1 year of age (15.0%). The overall mean patient age was
4.5 years with a median and mode of 3 and <1 year, respectively. The average age was
3.93 for Group A, and the median and mode were 3 and 1 year, respectively. For Group
B, the average age was 5.03 years, and the median and mode were 5 and <1 year, respectively.
We compared the prevalence of ENT (Group A) and non-ENT (Group B) diagnostic hypotheses
based on the patients' ages ([Chart 2]).
Chart 2. Relationship between patients with ENT and non-ENT diagnoses based on age when they
were treated at the emergency room during night shifts in 2011 at Hospital Santa Casa
de Misericordia Itatiba.
Among Group A patients, nonspecific infections of the upper airways were predominant
(77.2%), followed by otology background (8.7%), LPM (7.2%), nasal (3.4%), and others
(3.4%) ([Table 1]).
Table 1.
Number and percentage of diagnostic subtypes in Group A patients seen in the pediatric
emergency room of Hospital Santa Casa de Misericordia Itatiba in 2011 during night
shifts.
|
Diagnosed area
|
N
|
%
|
|
Upper airway infections
|
828
|
77.2
|
|
Ear
|
93
|
8.7
|
|
Larynx-pharynx-mouth
|
77
|
7.2
|
|
Nonspecific other
|
38
|
3.5
|
|
Nose
|
36
|
3.4
|
|
Total
|
1072
|
100
|
In Group B patients, there was a predominance of the gastrointestinal tract background
(29.0%), followed by trauma (20.9%), healthy patients(13.3%), diseases of the skin
and appendages (11.2%), lower respiratory tract (7.3%), other (5.4%), urinary tract
(4.4%), eyes and appendages (4.4%), and diseases related to the central nervous system
(4.1%) ([Table 2]).
Table 2.
Number and percentage of diagnostic subtypes in Group B patients treated at the pediatric
emergency room of Hospital Santa Casa de Misericordia Itatiba in 2011 during night
shifts.
|
Diagnosed area
|
N
|
%
|
|
Gastrointestinal tract
|
285
|
29.0
|
|
Other trauma
|
205
|
20.9
|
|
Healthy patients
|
131
|
13.3
|
|
Skin and appendages
|
110
|
11.2
|
|
Lower respiratory tract
|
72
|
7.3
|
|
Other diseases
|
53
|
5.4
|
|
Other diseases of the eye and appendages
|
43
|
4.4
|
|
Urinary tract
|
43
|
4.4
|
|
Diseases of the central nervous system
|
40
|
4.1
|
|
Total
|
982
|
100
|
The number of admissions served per shift increased during June and October for Group
A. The same was not observed for Group B.
Discussion
Increasingly, urgent emergency services are called upon to meet the shortage of basic
medical care, which is associated with ineffective public policy measures and hospital-envisioned
population. The same is true for specialized outpatient care, where high demand forces
patients to seek emergency treatment as an alternative[13].
Epidemiological studies on emergency services and pediatric emergencies are rare in
the literature and mostly focus on traumatology.
Otorhinolaryngological emergency studies have been conducted for services specializing
in this area. Thus, it is expected that studies on these services will reveal epidemiological
differences related to our study because it is a specialized service, the records
for nonspecific infections of the upper airways are not routinely included, and space
needs to be reserved for these patients in pediatric ERs.
Studies that relate complaints regarding the upper airways and other related otorhinolaryngology
areas in a general pediatric ER were not found.
In our study, we found a high prevalence of otorhinolaryngologic diagnoses in the
pediatric ER studied (52.2%), and this presents another reason for the expansion and
continuance of education otorhinolaryngology projects for pediatricians .
We also observed different average ages in the 2 groups: Group A patients (3.93 years)
were younger than Group B patients (5.03 years).
From observation of Group A alone, we noted a significant difference between the most
prevalent diagnosis (nonspecific UAI, 77.2%) and the second most prevalent diagnosis
(ear disease, 8.7%). We believe this difference stems from parents often taking their
children to a pediatric emergency room following initial symptoms, which usually include
fever, and sometimes the focus of infection has yet to appear (insufficient amount
of time).
If we were to exclude Group A patients who exhibit signs of nonspecific UAI (parents
usually seek treatment from a pediatric ER), we would discover a similar prevalence
to studies of ENT ERs: mostly for otology complaints, followed by LPM and nasal complaints[6]. Saha et al.[7], however, detected a higher prevalence of laryngeal complaints in a specialized
ER in India. This difference is possibly due to cultural peculiarities in that country,
in which the rate of foreign body detection in the larynx and esophagus is very high.
Group B demonstrated a predominance of complaints related to the gastrointestinal
tract because a large number of children develop acute gastroenterocolitis in some
seasons.
Group A demonstrated an increase in the number of consultations during June and October,
which can be explained by the increased frequency of respiratory disease during periods
of seasonal temperature changes.
Conclusion
A large number of patients seeking treatment in pediatric ERs receive otorhinolaryngologic
diagnoses.
