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Hi Julie - 

I spoke with 2 of the Pediatric Neurologists at my institution and here are their responses: 

- I do not think this was absence status. Yes, there is an immediate on off phenomenon, but respiratory depression is not a part of this.  Complex partial status is more likely to cause breathing problems, but they are tired after.
I would have gotten a MRI to look at her brainstem.  Vomiting, breathing changes are all in brainstem.  There may be a psychological component, but this is after an investigation is complete.  An EEG is also reasonable.

- I think this is most likely post-traumatic confusional migraine.  An EEG should have been done; there's high probability that it would have shown posterior slowing that likely would have improved/cleared as the patient herself cleared clinically.

Hope this helps. Curious to see how things turned out.

Best;

Camilo


Camilo E. Gutiérrez M.D.
Division of Pediatric Emergency Medicine – Boston Medical Center
Assistant Professor of Pediatrics – Boston University School of Medicine
88 E. Newton St, Vose 5
Boston, MA 02118
O: 617.414.3605 / 5514
F: 617.414.4393

________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Brown, Julie C. [[log in to unmask]]
Sent: Saturday, January 11, 2014 7:25 PM
To: [log in to unmask]
Subject: Re: PED-EM-L Digest - 9 Jan 2014 to 10 Jan 2014 (#2014-5)

Do you think you can see these respiratory changes with confusional migraine?  Others have suggested this dx as well.

Sent from my phone, please forgive brevity and typos.

> On Jan 11, 2014, at 5:15 AM, "Troy" <[log in to unmask]> wrote:
>
> Julie, if I saw this patient, given the course and outcome you describe, I'd call it an acute confusional migraine. It would be interesting to know if she had a history of headaches previous to this trauma; head trauma is a frequent trigger for migraines, and the time course, weird symptoms and resolution without treatment fit with migraine. You could call these symptoms concussive, but I haven't seen kids reporting the sensory changes you describe with concussion in most cases.
>
> Interesting patient for sure!
>
> Troy W.S. Turner
> Associate Professor, Pediatrics and Emergency Medicine
> University of Alberta
>
>
>
>> On Jan 10, 2014, at 22:00, "PED-EM-L automatic digest system" <[log in to unmask]> wrote:
>>
>> There are 4 messages totaling 368 lines in this issue.
>>
>> Topics of the day:
>>
>> 1. Minor head trauma and absence status? (2)
>> 2. Pelvic Ultrasound
>> 3. Pediatric EM Position - University of Maryland Baltimore
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> ----------------------------------------------------------------------
>>
>> Date:    Fri, 10 Jan 2014 00:09:28 +0000
>> From:    "Brown, Julie C." <[log in to unmask]>
>> Subject: Minor head trauma and absence status?
>>
>> I had a patient recently who had minor head trauma that I suspect may have been in absence status.  I wasn't able to find any similar reports in the literature.  I'm curious if anyone has seen this before.
>>
>> Here is the case:
>> A young teen was running around in a skateboard park, playing tag (in sneakers, not riding a skateboard).  She fell back onto her occiput, possibly on a ramp, so with a little more force than with a typical fall from standing on a level surface.  She didn't pass out.  She didn't vomit.  Eventually, she was able to describe the event and what happened afterwards, including seeing the school nurse and getting picked up by her parents.
>>
>> On return home, she complained of occipital headache 4/10, nausea, dizziness and blurry vision and some varying decreased sensation in her right then her left hand.  For these reasons, she was brought to the ED 40 mins after the event.  On evaluation, she was wretching and ultimately started vomiting.  Most of her exam was normal.  Her neuro exam was described as follows: Alert, moves all extremities, CN II-XII intact, Patient unable to consistently follow directions. When attempting to do finger-to-nose testing, patient grabs onto my finger instead of touching her nose. Also when testing for pronator drift she touches her wrist and palms together and does not hold her arms out straight. When asked if her sensation is intact bilaterally, she responds "I'm fine.".
>>
>> A head CT was obtained which was normal.  A drugs of abuse urine tox screen was negative. The patient was signed out to me with a plan to observe for a while and see if she improved, and if not, admit.  During the next hour or so, she remained confused, and started to have an unsual, rapid, shallow breathing pattern, while awake and talking (incomprehensibly) to me.  Repeatedly, when she fell asleep, she desaturated, initially to the 80's, then to the 60's, with a good tracing.  She was never cyanotic, but her nurse always quickly intervened by waking her up.  She was confused and had trouble expressing herself, saying things like 'I need to get this before me off my back' when trying to say she didn't like her cervical collar and wanted it off.  She could not follow commands.  For all these reasons, I consulted our PICU service, thinking her respiratory status was not sufficiently stable for the floor.  Half an hour later, the PICU attending and I walked into her room together, at which time she sat up, was conversant and coherent, described the events of the day in detail, denied significant headache, and could follow commands and do calculations.  Her breathing pattern was now normal.
>>
>> I was baffled at the time, as were her parents.  I let her fall asleep again, and when she didn't desaturate further, I admitted her to the ward service.  A while afterwards, I went home to sleep.  When I awoke, my very first thought on regaining consciousness was "she was in absence status."  This seems to make sense to me as it could explain her inability to follow commands, her respiratory changes, and her almost instantaneous recovery.  I called the inpatient team and suggested a Neurology consult, but the Neurologists didn't seem sold (and got a somewhat different version of events than what I witnessed), and didn't get an EEG.
>>
>> What do you all think?  Was my sleeping brain correct?  Or were these just post-concussive symptoms?  Have you ever seen a similar patient with absence status following minor head trauma?
>>
>> Julie
>>
>>
>> ***************************************
>> Julie Brown, MD, MPH
>> Associate Professor, University of Washington
>> Attending Physician, Pediatric Emergency Medicine,
>> Seattle Children's Hospital
>>
>>
>>
>>
>>
>> CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
>>
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>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> ------------------------------
>>
>> Date:    Thu, 9 Jan 2014 23:35:12 +0000
>> From:    Gill Winnik <[log in to unmask]>
>> Subject: Re: Pelvic Ultrasound
>>
>> Those patients will need most likely a blood draw anyhow so our nurses will place an angiocath at the same time.
>> A quick US done by us will check if the bladder is full and if not we will give a bolus NS and then check the bladder again with our US. Before shipping her to radiology for a formal US.
>>
>>
>> Giora Winnik
>> Maimonides  Brooklyn
>>
>>> On Jan 9, 2014, at 5:39 PM, "Pickett, Anthony" <[log in to unmask]> wrote:
>>>
>>> Typically, we will place a foley in the ED. Once in place, they will go to the Ultrasuond dept for the study.
>>>
>>>
>>> Anthony Pickett, M.D.
>>> Dept. of Emergency Medicine
>>> Phoenix Children's Hospital
>>> ________________________________________
>>> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Weiner, Evan J [[log in to unmask]]
>>> Sent: Thursday, January 09, 2014 1:55 PM
>>> To: [log in to unmask]
>>> Subject: Pelvic Ultrasound
>>>
>>> Hi everyone,
>>>
>>> Our department is evaluating our protocol for female Transabdominal Pelvic Ultrasonography, specifically how to get the bladder full in a timely fashion.  This is for patients that cannot get a Transvaginal ultrasound.
>>> If your ED has a protocol or standard practice for achieving this, I'd really appreciate it.
>>>
>>> Specifically,
>>> 1. Do you bolus a specific amount of IV fluid within a certain time-frame?
>>> 2. If not NPO, does your patient drink a certain amount of fluid within a certain time-frame?
>>> 3. Do you place a foley catheter to fill the bladder if not filled within a certain time-frame?
>>> 4. Do you defer urine testing until after the Ultrasound study, so that the patient does not empty bladder before filling it back up?
>>>
>>> Thanks a lot for your input.
>>>
>>> Evan J Weiner MD FAAP FACEP FAAEM
>>> Interim Director
>>> Department of Emergency Medicine
>>> Program Director, PEM Fellowship
>>> St. Christopher's Hospital for Children
>>> 3601 A Street
>>> Philadelphia, PA 19134
>>> 215-427-6089
>>> fax 215-427-4668
>>> [log in to unmask]
>>>
>>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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>>> This transmission, including any attachments, is for the sole use
>>> of the intended recipient (s) and may contain information that is
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>>
>>
>>
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>> ------------------------------
>>
>> Date:    Fri, 10 Jan 2014 12:14:01 -0500
>> From:    Michael Falk <[log in to unmask]>
>> Subject: Re: Minor head trauma and absence status?
>>
>> Just in the process of writing review article on Concussion and this would
>> strike me as a TBI/Concussion.  CT scans are useless in evaluating these
>> sorts of injuries and MRI's are often the same.  It's based on extensive
>> neurological evaluation and the persistence of symptoms despite a
>> "negative" evaluation (i.e. CT scan etc).
>>
>> Interestingly, the "force" associated with the actual blow is often not
>> perceived to be that "severe" but you will often find that it involves a
>> sudden back-to-front movement with a rotational aspect.  Part of the reason
>> that there has been serious push back by many to the concussion and CTE
>> research is that many of the injuries that are associated with these issues
>> have historically been perceived as not significant and that all the person
>> needs to do is shake it off (being "stunned" after "heading" a soccer ball!)
>>
>> Final note: one of my favorite teaching points for the residents is "always
>> consider the uncommon presentation of a common illness  before the common
>> presentation of an uncommon illness".
>>
>> Just my thoughts...hope it's helpful.
>>
>> Mike Falk
>> New York, NY
>>
>>
>> On Thu, Jan 9, 2014 at 7:09 PM, Brown, Julie C. <
>> [log in to unmask]> wrote:
>>
>>> I had a patient recently who had minor head trauma that I suspect may have
>>> been in absence status.  I wasn't able to find any similar reports in the
>>> literature.  I'm curious if anyone has seen this before.
>>>
>>> Here is the case:
>>> A young teen was running around in a skateboard park, playing tag (in
>>> sneakers, not riding a skateboard).  She fell back onto her occiput,
>>> possibly on a ramp, so with a little more force than with a typical fall
>>> from standing on a level surface.  She didn't pass out.  She didn't vomit.
>>> Eventually, she was able to describe the event and what happened
>>> afterwards, including seeing the school nurse and getting picked up by her
>>> parents.
>>>
>>> On return home, she complained of occipital headache 4/10, nausea,
>>> dizziness and blurry vision and some varying decreased sensation in her
>>> right then her left hand.  For these reasons, she was brought to the ED 40
>>> mins after the event.  On evaluation, she was wretching and ultimately
>>> started vomiting.  Most of her exam was normal.  Her neuro exam was
>>> described as follows: Alert, moves all extremities, CN II-XII intact,
>>> Patient unable to consistently follow directions. When attempting to do
>>> finger-to-nose testing, patient grabs onto my finger instead of touching
>>> her nose. Also when testing for pronator drift she touches her wrist and
>>> palms together and does not hold her arms out straight. When asked if her
>>> sensation is intact bilaterally, she responds "I'm fine.".
>>>
>>> A head CT was obtained which was normal.  A drugs of abuse urine tox
>>> screen was negative. The patient was signed out to me with a plan to
>>> observe for a while and see if she improved, and if not, admit.  During the
>>> next hour or so, she remained confused, and started to have an unsual,
>>> rapid, shallow breathing pattern, while awake and talking
>>> (incomprehensibly) to me.  Repeatedly, when she fell asleep, she
>>> desaturated, initially to the 80's, then to the 60's, with a good tracing.
>>> She was never cyanotic, but her nurse always quickly intervened by waking
>>> her up.  She was confused and had trouble expressing herself, saying things
>>> like 'I need to get this before me off my back' when trying to say she
>>> didn't like her cervical collar and wanted it off.  She could not follow
>>> commands.  For all these reasons, I consulted our PICU service, thinking
>>> her respiratory status was not sufficiently stable for the floor.  Half an
>>> hour later, the PICU attending and I walked into her room together, at
>>> which time she sat up, was conversant and coherent, described the events of
>>> the day in detail, denied significant headache, and could follow commands
>>> and do calculations.  Her breathing pattern was now normal.
>>>
>>> I was baffled at the time, as were her parents.  I let her fall asleep
>>> again, and when she didn't desaturate further, I admitted her to the ward
>>> service.  A while afterwards, I went home to sleep.  When I awoke, my very
>>> first thought on regaining consciousness was "she was in absence status."
>>> This seems to make sense to me as it could explain her inability to follow
>>> commands, her respiratory changes, and her almost instantaneous recovery.
>>> I called the inpatient team and suggested a Neurology consult, but the
>>> Neurologists didn't seem sold (and got a somewhat different version of
>>> events than what I witnessed), and didn't get an EEG.
>>>
>>> What do you all think?  Was my sleeping brain correct?  Or were these just
>>> post-concussive symptoms?  Have you ever seen a similar patient with
>>> absence status following minor head trauma?
>>>
>>> Julie
>>>
>>>
>>> ***************************************
>>> Julie Brown, MD, MPH
>>> Associate Professor, University of Washington
>>> Attending Physician, Pediatric Emergency Medicine,
>>> Seattle Children's Hospital
>>>
>>>
>>>
>>>
>>>
>>> CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is
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>>> and privileged information protected by law. Any unauthorized review, use,
>>> disclosure or distribution is prohibited. If you are not the intended
>>> recipient, please contact the sender by reply e-mail and destroy all copies
>>> of the original message.
>>>
>>> For more information, send mail to [log in to unmask] with the
>>> message: info PED-EM-L
>>> The URL for the PED-EM-L Web Page is:
>>>                http://listserv.brown.edu/ped-em-l.html
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>> ------------------------------
>>
>> Date:    Fri, 10 Jan 2014 14:28:49 -0500
>> From:    "Getachew Teshome, MD" <[log in to unmask]>
>> Subject: Pediatric EM Position - University of Maryland Baltimore
>>
>> Pediatric EM Position - University of Maryland Baltimore
>>
>> The University of Maryland School of Medicine, Department of Pediatrics is looking for a junior or mid level  Pediatric Emergency Medicine physician to join the Division of Pediatric Emergency Medicine. Level of academic appointment to commensurate with credentials.  Must be Board Certified in Pediatrics and Board Certified in Pediatric Emergency Medicine or dually trained and Board Certified in Pediatrics and Emergency Medicine.  We are recruiting a faculty member with established excellence in teaching, administration, patient care, and specified research interests.  Must demonstrate excellence as a clinician-educator.
>>
>> Competitive salary commensurate with qualifications and experience with a full benefit package.  The University of Maryland is a major tertiary medical center serving Baltimore, the State of Maryland and the region with innovative pediatric programs. Our Pediatric Emergency room is expanding as medical center is completing renovations to accommodate growing volumes. The University of Maryland has competitive residency programs in Pediatrics, family medicine, Emergency Medicine and a unique 5-year combined program in Pediatrics and Emergency Medicine.
>>
>> We are located near the downtown Inner Harbor area, just one of Baltimore's many outstanding attractions. From fine arts and orchestras to professional sports teams, first-class dining and shopping to a wealth of historical sites, our city offers a full range of recreational and cultural opportunities. Washington, D.C., Philadelphia and even New York City are within easy reach, as well as beaches to the east and mountains to the west. Educational excellence abounds, as do family-friendly neighborhoods and urban living options.
>>
>> The University of Maryland, Baltimore is an Equal Opportunity, Affirmative
>> Action employer. Minorities, Women, Veterans and individuals with disabilities
>> are encouraged to apply. Please refer to position #  03-314-401
>>
>> Interested individuals should submit a current curriculum vita to:
>>
>> Debra Counts, M.D.
>> Associate Chair of Clinical Affairs
>> Associate Professor of Pediatrics
>> Chief, Division of Pediatric Endocrinology
>> University of Maryland School of Medicine
>> 22 S. Greene St., Rm N6W84
>> Baltimore, MD 21201
>> [log in to unmask]
>>
>> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>> The URL for the PED-EM-L Web Page is:
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>>
>> ------------------------------
>>
>> End of PED-EM-L Digest - 9 Jan 2014 to 10 Jan 2014 (#2014-5)
>> ************************************************************
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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