UMEM Educational Pearls

Concussion Management in Children

What are the predictors of prolonged recovery of concussion in children?

Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.

Age:  As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.

Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.

Computer testing:  The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.

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Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.

Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:

1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results

2. positive CSF VDRL OR positive CSF FTA-ABS test result 

3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)

4. clinical symptoms

This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.  

Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.

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• High-quality CT is adequate for clearing c-collar in obtunded patients.
• A follow-up exam before discharging the patient strengthens your decision making and documentation.
• MRI can be reserved for high-risk patients, patients who are being admitted to surgical critical care units, and those who have residual findings once alert.

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Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).

CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours.  It rapidly decreases once the inflammation has resolved.

An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).

A CRP >75 mg/L increased the relative risk of SBI by 5.4.

A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.

In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them).  A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.

Bottom line:

CRP is not a rule in/rule out test

CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment

CRP has a limited role in well appearing children older than 3 months

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• History of regular cannabis use at least weekly for any duration of time.
• Compulsive hot water bathing multiple times per day for symptom relief which is mediated by the TRPV capsaicin receptors.
• Resolution of symptoms with cannabis cessation.
• Prior nonrevealing extensive diagnostic work up.

CHS Treatment:

• Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.
• Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.

Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea. 

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You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….

“What about school?”

An athlete should not return to play until they have successfully returned to school

Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms

                -school work, TV, videogames, texting

Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!

Step 1: 24 to 48 hours of rest

Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.

                Home work, reading assignments, other cognitive activities

Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.

Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).

Suggested examples of adjustments:  Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.

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Does using a combination of aspirin and clopidogrel decrease your patient’s risk of recurrent stroke after a minor ischemic stroke or high risk TIA event?

• The recent international Platelet-Oriented Inhibition in New TIA and Minor Stroke (POINT) trial compared 4881 patients receiving aspirin/clopidogrel vs. aspirin/placebo within 12 hours of symptom onset.
  • Patients who received DAPT had a lower rate of major ischemic events at 90 days compared to aspirin/placebo (5.0% vs. 6.5%, p=0.02).
  • However, patients who received DAPT had a higher rate of major hemorrhage compared to aspirin/placebo (0.9% vs. 0.4%, p=0.02).
• A similar Chinese study, the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial, compared 5170 patients receiving DAPT vs. aspirin/placebo within 24 hours also found lower rate of stroke (8.2% vs. 11.7%, p<0.001) but similar rates of moderate/severe hemorrhage (0.3% vs. 0.3%, p=0.73).
• Major differences between these two trials are the population studied and the duration of DAPT, as POINT utilized DAPT for 90 days while CHANCE utilized DAPT for 21 days.

Bottom Line: The use of DAPT in minor ischemic stroke and high risk TIA reduces the risk of recurrent stroke.  However, the duration of DAPT may affect the risk of major hemorrhage.

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We know that high flow nasal cannula is an option in the management of acute hypoxic respiratory failure without hypercapnea. A newer iteration of high flow, "high velocity nasal insufflation" (HVNI), may be up-and-coming.

According to its makers (Vapotherm), it is reported to work mainly by using smaller bore nasal cannulae that deliver the same flows at higher velocities, thereby more rapidly and repeatedly clearing dead space, facilitating gas exchange and potentially offering ventilatory support. 

In an industry-sponsored non-inferiority study published earlier this year:

• 204 adult patients in 5 EDs
• Any acute respiratory failure deemed by the treating physician to require non-invasive positive pressure ventilation (NPPV)
• Patients randomized to either NPPV (bilevel positive airway pressure) or HVNI
• Rate of HVNI treatment failure (26%) and intubation @ 72 hours (7%) fell within predefined noninferiority margins
• Rates of PCO2 clearance were similar between HVNI and NPPV groups
• The study was not powered to detect differences between different etiologies for respiratory failure
• Authors concluded that HVNI is noninferior to NPPV for all-comer respiratory failure.

Bottom Line: 

The availability of a nasal cannula that helps with CO2 clearance would be great, and an option for patients who can't tolerate the face-mask of NPPV would be even better.

HVNI requires more investigation with better studies and external validation before it can really be considered noninferior to NPPV, but it certainly is interesting. 

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Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.

When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route.  Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen.  Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.

Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.

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25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4^th and 5^th digits.

What physical examination maneuvers can you do at the bedside to assist in the diagnosis?

               Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.

Flexing elbow to 20 to 30 degrees unlocks the olecranon

1. Valgus stress test – flex elbow with forearm/hand supinated. Apply valgus stress test and note for laxity/firm endpoint.

https://www.youtube.com/watch?v=KXQxH0UTn-8

2. Milking maneuver – Here the valgus stress is created by pulling on the patient’s thumb with the forearm supinated and elbow flexed to 90°. Note instability, pain, or apprehension.

https://www.youtube.com/watch?v=4sa9goJ4afs

or

https://www.youtube.com/watch?v=SwigwaZxBXE

3. Moving valgus stress test – Similar to the milking maneuver, the valgus stress test is applied while the elbow is ranged through full flexion and extension. Note instability, pain, or apprehension in mid range (between 70 and 120 degrees)

https://www.youtube.com/watch?v=OnkkHpG3Dqg

Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually)  seizure disorder in young kids, generally less than 1 year old.  Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description.  The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.

A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.

Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.

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Question

A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip".  His physical exam :

Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.

Skin: Dry, hot , flushed

HEENT: Marked mydriasis 6mm

Lungs: Clear

Heart: Tachycardic

Abdomen: Distended tender suprapubic with absent bowel sounds,

Neuro: Extremely agitated pacing, no muscular rigidity.

What has he ingested and what is the treatment?

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Sedating Mechanically Ventilated Patients

• Providing appropriate analgesia and sedation to mechanically ventilated patients is of paramount importance.
• In a recent systematic review and meta-analysis, Stephens et al. assessed the impact of deep sedation within the first 48 hours of initiation of mechanical ventilation.
• In 9 studies that included over 4,500 patients, deep sedation within the first 48 hours of initiation of mechanical ventilation was associated with increased mortality, increased ICU LOS, and increased frequency of delirium.
• Take Home Points
  • When possible, target lighter levels of sedation in mechanically ventiilated patients.
  • Though no universally accepted definition of light sedation exists, most studies use a RASS of -2 to +1

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The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Key Recommendations:

1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)

2. Use validated, age-appropriate symptoms scales to diagnose mTBI

3. Assess evidence-based risk factors for prolonged recovery.  No single factor is strongly predictive of outcome.

4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)

5.  Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.

A wealth for information and tools for provder and families can be found at:

www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)

www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html

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Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.

Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed. 

Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses

• Cutaneous reaction (urticarial, pruritus and angioedema) occurred in 398 (75.4%)
• Systemic reaction (respiratory symptoms or hypotension): 34 (6.4%)
• Both reactions: 96 (18.2%)

Over 90% patients developed analphylatoid reaction within 5 hours.

Onset of reaction: 

• 1^stNAC dosing (150 mg/kg over 1 hour): 133/528
• 2^ndNAC dosing (50 mg/kg over 4 hours): 371/528
• 3^rdNAC dosing (100 mg/kg over 16 hours): 24/528

Administered medication for treatment

• Antihistamine: 371
• Beta-2 agonist: 15
• Epinephrine: 10
• Corticosteroids: 7

Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes

• Female
• Single acute ingestion
• Low serum acetaminophen level.

Bottom line

1. Anaphylactoid reaction to NAC is uncommon
2. Cutaneous symptoms are most common
3. Female, single acute ingestion and low serum acetaminophen levels are associated with incidence of anaphylactoid reaction. 

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The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...

• Multicenter, open-label, RCT, 26 French ICUs
• Adult patients with pH < 7.2 not secondary to hypercapnia, serum bicarb < 20 not due to bicarb wasting process 
• SOFA score > 4 or lactate > 2
• No bicarb versus 4.2% sodium bicarb infusion titrated to pH >7.3
• Primary outcome: Composite measure of 28-mortality and presence of any organ failure at 7 days post-randomization
• Secondary outcomes: Need for/length of life support measures (renal-replacement, vasopressors, mechanical ventilation), SOFA score after enrollment, electrolyte effects, occurrence of ICU-acquired infections, and ICU length of stay
• Major findings:
  • No difference in primary outcome overall
  • No difference in pressor-free days, days off RRT, dialysis dependence at ICU discharge, ICU LOS
  • Bicarb group had less need for RRT during ICU stay (35 vs 52%, p=0.0009)
  • In patients with AKI and AKIN score 2-3*, the bicarbonate group had a decrease in both 28-day mortality (46 vs 63%, p=0.0166) and presence of any organ failure at day 7 (66 vs 82%, p=0.0142)
• Limitations:
  • Unblinded
  • A quarter of the control group actually received bicarb
  • No data regarding vent settings, ABGs to r/o ventilation effects on pH
  • 4.2% is not a standard concentration of bicarb used in the U.S.

Bottom Line: 

Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).

*Acute Kidney Injury Network Staging Criteria

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Froment’s Sign

Tests for motor weakness of the Ulnar nerve

Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands

Examiner then pulls on the paper

Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper

https://handlab.com/resources/wp-content/uploads/2014/04/June-2013-No25.jpg

Does Lactated Ringer's Raise Serum Lactate?

• Intravenous fluid administration is a cornerstone of resuscitation and the treatment of many critically ill ED patients.
• Recent publications have suggested that balanced crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
• Lactated Ringer's (LR) is a common balanced crystalloid solution often used for fluid resuscitation in critically ill patients.
• AS LR contains approximately 28 mmol/L of sodium lactate, the question of whether LR elevates serum lacate is frequently asked.
• In a recent small, randomized, double-blind, controlled trial, investigators randomized healthy volunteers to receive 30 ml/kg of either 0.9% NS or LR. The authors report no statistical difference in the mean serum lactate when comparing LR to 0.9% NS.

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