Hot Seat #31 Denouement: The Double Bounceback

by Marina Gore, Inova Fairfax

with Nazreen Jamal, Children's National, on the Hot Seat

Case edited by Emily Willner, Children's National

The Case

This is was a case of a 9 year-old boy who came back to the ED three times in a week for various complaints including headache and fever. He has had a recent reassuring head CT and LP showing 300 WBC (90% lymphocytes) and negative viral studies. On exam, he is difficult to arouse and has a limited ROM of his neck on exam. For a complete case presentation, click here. 

Here's how your answered our questions

Which of the following is your highest priority next step?

Less than 3 years PEM experience (n=15)

Greater than 3 years PEM experience (n=14)

Both sets of providers had similar priorities. The largest majority of both wanted to repeat the head CT despite it being normal only several days ago. The next largest proportion wanted to give Narcan followed by a segment that wanted to give mannitol or hypertonic saline out of concerns about ICP.

A short while later he is still very somnolent. CT head is grossly unchanged from the one obtained 1 week ago, without abnormalities. Utox +opiate only. CBC, lytes, LFTs and ammonia WNL. You give a dose of Narcan and the patient becomes a more alert, but screams and writhes in pain: "Ow, my head is killing me!"
 
What is your next management step now?

Less than 3 years PEM experience (n=19)

Greater than 3 years PEM experience (n=15)

The largest proportion of providers in both groups were interested in get a STAT MRI. A larger proportion of providers with less than 3 years PEM experience were being coy and wanted to do none of the options provided compared to the providers with more than 3 years PEM experience. What other options did people have in mind in this situation? On the other hand, a larger proportion of providers with more than 3 years PEM experience wanted to get a blood patch for this patient.

Clinical Reasoning

On the differential diagnosis
"I would worry about: 1- increased ICP, though a nl CT a few days ago is reassuring secondary to an infection abscess missed previously, though doubtful with the initial CSF findings, or bacterial, or worsening viral meningitis 2- Bacterial meningitis potentially caused by the LP done (lack of fevers on tyl 3 Q6 is not the most accurate) 3- Opioid OD (tyl 3 around the clock with pinpoint pupils) 4- CSF leak from previous LP, though the ones I've encountered tend to cause headaches and severe discomfort, but no stiff neck, AMS or abnormal VS." -Rasha Sawaya, Children's National

"Some of the immediate worrisome aspects: bradycardia with hypertension, suggestive of increased ICP; and bradypnea. To take the 2nd one first, the combination of breathing slowly and pinpoint pupils is likely related to the codeine intake. So it makes sense to give Narcan." -Jennifer Chapman, Children's National

On the repeat imaging

"I would start with a repeat CT (because of VS) though one could argue to give the narcan 1st (pinpoint pupils and worsening sx)" -Rasha Sawaya, Children's National

"...given that he is going to be rescanned, I would have chosen a contrast head CT. This would also give the advantage of lighting up the meninges if he has a viral infection (I think)." -Jennifer Chapman, Children's National

On what to do next
"This pt appears to have improved with narcan though pain is worse. This I think could be from opiate withdrawal since he's been taking Tyl 3 for several days. So i would give toradol, get a Pain team consult (methadone? Or too soon?) and have more narcan ready at the bedside as the 1 dose may not be enough for him since he has had opiates in his system for several days now." Rasha Sawaya, Children's National

"Given pain meds as Rasha suggested, review chart and make decision around given antibiotics (probably not) and acyclovir (possibly). Labs already done. Order MRI of the head with contrast. Admit to PICU if his vital signs remain abnormal; to the floor only if he is mentating better than at admission." -Jennifer Chapman, Children's National

From the Hot Seat

by Nazreen Jamal, Children's National

Great case, certainly one that would give me some pause in the ED. My initial focus, as Jennifer and Rasha highlighted, were the elevated BP and low HR that are concerning for increased ICP. The history of T#3 use with pinpoint pupils and slow (not irregular) respirations make me think that opioid use is potentially confounding the picture, as it can certainly cause somnolence, bradycardia, and respiratory depression, but I would expect relative hypo, not hypertension, so it doesn't explain the whole picture. My approach would likely be to draw up 3% at the bedside (but not give it at this point) while getting access and bedside VBG/lytes/glucose, putting the patient on an ETCO2 monitor. I would likely give a dose of Narcan to see if the opioid use was affecting the patient’s mental status and improve my ability to get a more complete neurologic exam. I would think about giving incremental low dose Narcan (0.4 mg) as recommend for therapeutic opioid toxicity, as giving the full reversal dose of 2 mg for someone on opioid therapy may precipitate severe pain . 

At this point, if he is more awake but still altered with abnormal vital signs, I would feel obliged to re-image (but not intubate). As Jennifer noted, I would be worried about meningo-encephalitis and would order a CT with contrast. Brain abscess also crossed my mind, but the lack of persistent fever without antimicrobials and non-focal exam goes against this. Though an MRI would be ideal, with hypertension and bradycardia, I think more urgent imaging is indicated, and a CT with contrast would be the fastest substitute. 

This is a patient I would accompany to the scanner on full monitors, 3% in hand in case of any change in pupillary or respiratory exam. Along the way, I would be trying to figure out where the original presentation of abdominal pain fits into his diagnosis and make sure I’m not missing anything, but not many things pop into my mind. Mycoplasma encephalitis can be accompanied by GI symptoms, so would add it to the myriad list of diseases to test for with a working diagnosis of encephalitis. I would admit the patient to the PICU, defer LP at this time with the thought that that this is progression of the same etiology that caused the meningitis, and discuss with Neuro/ID for tests to send from the ED while awaiting the PICU bed. Of course, if he becomes increasingly somnolent unresponsive to narcan, has increasing ETCO2s, loses his gag, etc, would have to intubate, but otherwise would watch him very closely until he goes to the PICU.. and would then stalk the progress notes to find out what his diagnosis turns out to be… 

Denouement

by Marina Gore, INOVA Fairfax 

The patient was admitted. He had an MRI and repeat LP. The MRI showed no acute intracranial abnormality. The repeat LP showed WBC 70 (88% lymphs) , RBC 0, protein 82.5, HSV negative. The patient was started on steroids, which improved his headache. He had improved but persistent gait abnormalities at discharge. 

The altered mental status was likely due to narcotics while the headache and persistent neck rigidity was secondary to the resolving viral meningitis.

He is scheduled for neurology and neuro-ophthalmology outpatient follow-up. When called at home, the family said that the patient is doing well, has gone back to school, and is his independent self again.
 
Editor's Note
by Sonny Tat, Children's National
 
This patient's somnolence confused an already challenging clinical situation and was likely caused by the codeine in Tylenol #3, which was prescribed earlier. Not everyone who has been on Tylenol #3 for a few days becomes obtunded or difficult to arouse. Recent data has reported deaths in children post-tonsillectomy who have received codeine-based pain medications. Authors suggest these deaths are related to children who are ultra-rapid metabolizers of codeine, which leads to higher levels of conversion of codeine to morphine. The data and variable pharmacokinetics has led the FDA to place a black box warning on using codeine for post-tonsillectomy patients and other authors to suggest that codeine is on it's way out as a drug of choice for pediatric pain control. 

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.