Isolated loss of consciousness and risk for clinically important traumatic brain injury

Continuing onward with the top ten articles presented at the recent AAP NCE in San Diego is yet another secondary analysis of the original PECARN study on clinically important TBI (ciTBI). This time looking at children with isolated loss of consciousness (LOC). The outcomes were ciTBI which resulted in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors). They defined LOC as seen in Table 1:

Image not available.

Isolated loss of consciousness in children with minor blunt head trauma

Lee LK, Monroe D, Bachman MC, Glass TF, Mahajan PV, Cooper A, Stanley RM, Miskin M, Dayan PS, Holmes JF1, Kuppermann N1; Traumatic Brain Injury (TBI) Working Group of Pediatric Emergency Care Applied Research Network (PECARN). JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

The bottom line

Loss of consciousness is common in head injuries presenting to the ED, but unless it occurs with other worrisome symptoms or historical factors the risk of clinically important traumatic brain injuries is very low and CT scans are likely not necessary.

What they did

Recall that the original study had 42,412 children of which 15.4% had LOC (6.286). The authors of this study included children with blunt head trauma evaluated within 24 hours of injury and GCS >14. They excluded the those with very minor trauma, and those who were significantly injured. In summary they noted the following:

  • The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5)
  • The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780)
  • When comparing children who have isolated LOC with those who have LOC and other PECARN predictors (see Table 1 above), the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19)

What you can do

  • Recognize that up to 1 in 7 children with head injuries may have LOC
  • Know that if LOC is the only presenting historical factor the overall risk of ciTBI is very low (<1/200) and not getting a CT scan in lieu of observation may be warranted for many patients
  • Recognize that if patients have other symptoms/historical factors AND LOC then the risk of ciTBI is higher, and you may want to consider getting a CT scan
  • Know that parents may be very alarmed by witnessing a LOC. Spend time providing reassurance and be thorough in your evaluation and provision of anticipatory guidance.

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About rapid flu tests…

I’m sure that many of you are seeing significant volumes in your Emergency Departments. Certainly a lot of it is being driven by flu/concerns about flu/rumors about flu etc,. Here are a few things I want you to remember;

  • In a meta-analysis of 60 studies of rapid influenza antigen tests in children, the pooled sensitivity of rapid influenza antigen tests was 66.6 percent (95% CI 61.6-71.7 percent) and the pooled specificity was 98.2 percent (95% CI 97.5-99 percent) – adult sensitivity is about 54% for reference. This means that it has a good positive predictive value, but a fair negative predictive value.
  • Supplies of Influenza A/B rapid antigen kits will deplete quickly
  • Restrict the use of the rapid antigen test to those situations when it will change your patient management. Thus, if you are going to start antivirals because the patient is high-risk, and it is within 48 hours – then test. Read the CDC’s web site on antivirals for comprehensive information. In short, antivirals are for immunocompromised, chronic pulmonary disease, the young, the old and pregnant women.
  • If you are doing the test as the part of a workup of a febrile neonate or an immunocompromised child then go ahead and test.
  • If you need a highly sensitive and can wait (admitting a child for instance) get the respiratory PCR test for influenza A/B. It sometimes comes as a part of a panel.


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Are we giving too much ondansetron?

Next up from the top ten articles presented at the recent AAP NCE in San Diego is a retrospective observational analysis from Freedman et al. on the increasing use of ondansetron and its effects on clinic outcomes in children. Certainly many of you have written for ondansetron. I have written about ondansetron; including a Why We Do What We Do focusing on the evidence behind its use, a companion podcast, and a Briefs on the curious tendency of its association with increased risk of return to the ED.

Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis

Freedman SB, Hall M, Shah SS, Kharbanda AB, Aronson PL, Florin TA, Mistry RD, Macias CG, Neuman MI. JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

The bottom line

We are giving too much ondansetron, especially to kids who aren’t really in need of or at risk for needing IV rehydration.

What they did

The authors performed a retrospective observational analysis of children under the age of 18 diagnosed with gastroenteritis via a large database that included 18 Pediatric Emergency Departments. Oral ondansetron use was studied at a hospital level and categorized based on percentage of use in eligible patients: low (<5% administered ondansetron), medium (5%-25%), or high (>25%). This study was concerned with transitions between usage rates as ondansetron became more en vogue. The primary outcome was IV rehydration, and the secondary outcomes were hospitalization and emergency department revisits within 3 days. They noted the following:

  • Oral ondansetron use (median institutional rate per this study) increased substantially between 2002 and 2011 –  from 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001)
  • Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration
  • IV rehydration rates only decreased slightly as ondansetron use grew; 43,41/232,706 (18.7%) during period of low use to 59,450/334,264 (17.8%) during the high use period (adjusted percentage change = −0.33%; 95% CI, −1.86% to 1.20%)
  • No change in the hospitalization rate (adjusted percentage change = −0.33%; 95% CI, −0.95% to 0.29%)
  • Emergency department revisits decreased (adjusted percentage change = −0.31%; 95% CI, −0.49% to −0.13%)
  • Median adjusted total hospital costs/patient increased from $252 to $307

The above results take into account the aggregate data across 18 hospitals. Though overall rates of IV fluids, admission and ED revisits did not change substantially, these changes were more pronounced in hospitals with varying levels of usage. One-third of the hospitals did see a reduction in IV fluid administration rates, and 3/18 saw a reduction in admission rates when ondansetron use increased. So it appears as though some facilities used it in the right clinical scenarios, at least according to the RCTs.

What you can do

  • Recognize that for children with mild to moderate dehydration oral rehydration therapy (ORT) is the first line treatment option
  • In the right situation ondansetron may reduce the need for IV fluids or admission
  • In that this study showed no rise in rates of IV fluid administration concomitant with increased use of ondansetron suggests that we may be giving it too frequently in the Emergency Department
  • Find out if ondansetron is protocoled/bundled in your ED and thus being given less discriminately than it should
  • As yourself the following:
    • How frequently are you using ondansetron?
    • Are you using it for the right patients?
    • Are you providing adequate patient education and guidance?
  • Know that just giving it to stop a patient from vomiting is not something that we should do just for the sake of “customer service” alone. Spending adequate time addressing parental concerns about why the vomiting is occurring and providing reassurance is likely to be highly effective as well.

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Assessing for cerebral edema in DKA

Adapted from Muir et al, Diabetes Care, 2004 here is a protocol/schema that can guide in the assessment of cerebral edema in DKA. Recall that the symptoms of cerebral edema vary, and it can be especially difficult to diagnose as findings will occur ahead of CT/MRi changes. One-half to 1% of patients in DKA have cerebral edema, the mortality of which approaches 20%. The authors noted that in their small sample it was 92% specific and 96% sensitive.

You should use this tool only after therapy (insulin/fluids) has begun. You should suspect cerebral edema if:

Any diagnostic criteria
2 major criteria
1 major and 2 minor

Diagnostic criteria

  • Abnormal motor or verbal response to pain
  • Decorticate or decerebrate posture
  • Cranial nerve palsy (especially III, IV, and VI)
  • Abnormal neurogenic respiratory pattern (eg, grunting, tachypnea, Cheyne-Stokes, apneusis)

Major criteria

  • Altered mentation/fluctuating level of consciousness
  • Sustained heart rate deceleration (≥ 20 beats per minute) not attributable to improved intravascular volume or sleep state
  • Age-inappropriate incontinence

Minor criteria

  • Vomiting
  • Headache
  • Lethargy or being not easily aroused from sleep
  • Diastolic blood pressure >90 mmHg
  • Age <5 years

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