Which Febrile Children With Sickle Cell Disease Need a Chest X-Ray?

Eisenbrown K, Nimmer M, Ellison AM, Simpson P, Brousseau DC.

Academic Emergency Medicine, 2016

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The Bottom Line

Following the NHLBI criteria and paying attention to the presence of chest pain and/or elevated WBC can help you decide when to order a chest X-Ray – because not everybody presenting to the ED needs one.

What They Did

  • A retrospective review of nearly 2,000 children 3 months to 21 years with sickle cell disease with fever (≥38.5°C)
  •  The primary outcome was the presence of Acute chest syndrome (ACS( – 187  of the original sample had it
    • Per the NHLBI “ACS is an acute illness characterized by fever and respiratory symptoms, accompanied by a new pulmonary infiltrate on a chest x ray.”
    • The NHLBI recommends a chest X-Ray if the patient has shortness of breath, tachypnea, cough, or rales.
  • Test characteristics of their model were as follows:

  • The NHLBI Chest X-Ray criteria identified 85% of ACS cases and avoided 825 unneeded Chest X-Rays
  • They also recommendObtaining a CXR in children with NHLBI criteria or chest pain and in children without those symptoms but with a white blood cell (WBC) count ≥18.75 9 109/L or a history of ACS identified 181 (98%), while avoiding 430 CXRs.

What You Can Do

  • You should have a high index of suspicion for ACS in children with SCD and any of the following
    • NHLBI criteria
    • Chest pain
    • Children without NHLBI criteria or chest pain but a WBC count ≥18.75 9 109/L or a history of ACS