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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Azouz H, Muhammed W, Abd Elmaksoud M. Clinical Characteristics and Appropriateness of Investigations in Children With Headaches at the Emergency Department. Pediatr Neurol 2024; 154:58-65. [PMID: 38531164 DOI: 10.1016/j.pediatrneurol.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/25/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Identifying the cause of headaches in pediatric emergency departments (PEDs) can be challenging due to the lack of comprehensive research. This study aims to identify the frequency, characteristics, and unnecessary diagnostic procedures of patients with headaches in the PED setting. METHODS A six-month cross-sectional study was conducted at the PED of Alexandria University Children's Hospital, including all children with headaches. Children were classified as having primary headache (PH), secondary benign headache (SBH), and secondary serious headache (SSH) according to predetermined criteria. Logistic regression was employed to analyze the risk factors associated with SSH. RESULTS A total of 164 visits to the PED were recorded, out of a total of 22,662 visits, accounting for approximately 0.72% of all visits and 1.17% of the total number of children admitted. PH was the most common cause, accounting for 61.0% of cases, followed by SSH with 24.4%, whereas SBH was the least common with 13.4%. Abnormal neurological examination (odds ratio, 53.752 [1.628 to 1774.442], P = 0.026∗) was found to have a strong and statistically significant association with SSH in the multivariate analysis. Regarding the appropriateness of the investigations conducted, it was found that over half (66.5%) of the cases had unnecessary neuroimaging, with 52% of these cases being children with PH. CONCLUSIONS Headaches in children are commonly reported during visits to the PED. PH was the most prevalent, followed by SSH, whereas SBH was the least common. Many of the children received inaccurate first diagnoses and performed unnecessary laboratory tests, neuroimaging, and other tests, mostly electroencephalography.
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Affiliation(s)
- Hanan Azouz
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt
| | - Wafaa Muhammed
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt
| | - Marwa Abd Elmaksoud
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt.
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Lopez-Rippe J, Schwartz ES, Davis JC, Dennis RA, Francavilla ML, Jalloul M, Kaplan SL. Imaging Stewardship: Triage for Neuroradiology MR During Limited-Resource Hours. J Am Coll Radiol 2024; 21:70-80. [PMID: 37863151 DOI: 10.1016/j.jacr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES To decrease call burden on pediatric neuroradiologists, we developed guidelines for appropriate use of MR overnight. These guidelines were implemented using triage by in-house generalist pediatric radiologists. Process measures and balancing measures were assessed during implementation. METHODS For this improvement project, interdepartmental consensus guidelines were developed using exploratory mixed-methods design. Implementation of triage used plan-do-study-act cycles. Process measures included reduction in the number of telephone calls, frequency of calls, triage decisions, and number and type of examinations ordered. Balancing measures included burden of time and effort to the generalist radiologists. Differences in examination orders between implementation intervals was assessed using Kruskal-Wallis, with significance at P < .05. RESULTS Consensus defined MR requests as "do," "defer," or "divert" (to CT). Guidelines decreased neuroradiologist calls 74% while adding minimal burden to the generalist radiologists. Most nights had zero or one triage request and the most common triage decision was "do," and the most common examination was routine brain MR. Number of MR ordered and completed overnight did not significantly change with triage. DISCUSSION Multidisciplinary consensus for use of pediatric neurological MR during limited resource hours overnight is an example of imaging stewardship that decreased the burden of calls and burnout for neuroradiologists while maintaining a comparable level of service to the ordering clinicians.
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Affiliation(s)
- Julian Lopez-Rippe
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin S Schwartz
- Division Chief Neuroradiology and Associate Chair for Diversity, Equity, and Inclusion, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Professor of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Christopher Davis
- Section Director for Emergency Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca A Dennis
- Director of Fellowship, Residency and Observership Program, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L Francavilla
- Associate Professor and Chief Medical Information Officer for Radiology, Department of Radiology, University of South Alabama, Mobile, Alabama
| | - Mohammad Jalloul
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Summer L Kaplan
- Associate Chair for Quality and Medical Director of Point-of-Care Ultrasound, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Alhashem R, Byrne S, Hall D. Fifteen-minute consultation: Diagnosing serious pathology in children with headaches presenting to the emergency department. Arch Dis Child Educ Pract Ed 2023; 108:401-405. [PMID: 35803699 DOI: 10.1136/archdischild-2021-323329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/27/2022] [Indexed: 11/03/2022]
Abstract
Headache is one of the most common presentations to the paediatric emergency department. Although challenging, it is important to differentiate serious secondary headaches requiring emergency treatment from primary headache disorders. A detailed history and neurological examination can be used to identify children at higher risk of serious underlying pathology. Neuroimaging decisions should be taken carefully, weighing risk versus benefit in each case. This article will discuss five patient scenarios highlighting red flags and differential diagnoses in children presenting with headache in the emergency department.
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Affiliation(s)
- Roqiah Alhashem
- Emergency Department, Children's Health Ireland at Crumlin, Dublin, Ireland
- Department of Paediatrics, Qatif Central Hospital, Qatif, Saudi Arabia
| | - Susan Byrne
- Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- FutureNeuro, Paediatric Department, RCSI, Dublin, Ireland
| | - Dani Hall
- Emergency Department, Children's Health Ireland at Crumlin, Dublin, Ireland
- Blizard Institue, Queen Mary University Hospital of London, London, UK
- University College Dublin, Dublin, Ireland
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Tsze DS, Kuppermann N, Casper TC, Barney BJ, Richer LP, Liberman DB, Okada PJ, Morris CR, Myers SR, Soung JK, Mistry RD, Babcock L, Spencer SP, Johnson MD, Klein EJ, Quayle KS, Steele DW, Cruz AT, Rogers AJ, Thomas DG, Grupp-Phelan JM, Johnson TJ, Dayan PS. Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol. BMJ Open 2023; 13:e079040. [PMID: 37993148 PMCID: PMC10668138 DOI: 10.1136/bmjopen-2023-079040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - T Charles Casper
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bradley J Barney
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lawrence P Richer
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada
- Department of Pediatrics, Division of Neurology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danica B Liberman
- Departments of Pediatrics and Population and Public Health Sciences, Division of Emergency and Transport Medicine, University of Southern California Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Pamela J Okada
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jane K Soung
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rakesh D Mistry
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lynn Babcock
- Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sandra P Spencer
- Department of Pediatrics, Division of Emergency Medicine, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michael D Johnson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eileen J Klein
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Dale W Steele
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Warren Alpert Medical School and School of Public Health of Brown University, Providence, Rhode Island, USA
| | - Andrea T Cruz
- Department of Pediatrics, Divisions of Emergency Medicine & Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Danny G Thomas
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Tiffani J Johnson
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Cappellari AM, Bruschi G, Beretta GB, Molisso MT, Bertolozzi G. How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1837. [PMID: 38136039 PMCID: PMC10742139 DOI: 10.3390/children10121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Bruschi
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Gisella B. Beretta
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Maria T. Molisso
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giuseppe Bertolozzi
- Pediatric Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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Ko TS, Catennacio E, Shin SS, Stern J, Massey SL, Kilbaugh TJ, Hwang M. Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children. Neurocrit Care 2023; 38:791-811. [PMID: 36949362 PMCID: PMC10241718 DOI: 10.1007/s12028-023-01690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.
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Affiliation(s)
- Tiffany S Ko
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Eva Catennacio
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Samuel S Shin
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Joseph Stern
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
| | - Shavonne L Massey
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
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Tang PH, Zhang AY, Lam SSW, Ong MEH, Chan LL. Implementation of an AI model to triage paediatric brain magnetic resonance imaging orders. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abu‐Rumeileh S, Beltrami G, Di Maurizio M, Indolfi G, Trapani S. Bartonella henselae vertebral osteomyelitis in a pediatric patient: A case report. Clin Case Rep 2022; 10:e6117. [PMID: 36276906 PMCID: PMC9582676 DOI: 10.1002/ccr3.6117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/14/2022] [Accepted: 07/02/2022] [Indexed: 11/09/2022] Open
Abstract
Bartonella henselae is an unusual and rarely suspected osteomyelitis etiologic agent. We present a case of low back-pain in a 10-year-old female which lead to a challenging diagnostic work-up due to subtle imaging findings. The diagnosis was Bartonella henselae vertebral osteomyelitis mimicking bone tumor.
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Affiliation(s)
- Sarah Abu‐Rumeileh
- Postgraduate School of PediatricsUniversity of Florence and Meyer Children's University HospitalFlorenceItaly
| | - Giovanni Beltrami
- Division of Pediatric Oncological OrthopedicsMeyer Children's University HospitalFlorenceItaly
| | | | - Giuseppe Indolfi
- Department of NEUROFARBAUniversity of Florence and Meyer Children's University HospitalFlorenceItaly
| | - Sandra Trapani
- Department of Health SciencesUniversity of Florence and Meyer Children's University HospitalFlorenceItaly
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Abstract
Headache represents one of the most common disorders in childhood and leads to nearly half a million visits to the physician's office or emergency department every year. Although the estimated prevalence is around 58.4%, the actual incidence of headache in the pediatric population might be underestimated, given only a percentage of cases seek medical attention. The first step in the evaluation of pediatric headache is a detailed clinical history and relevant clinical examinations. AAN and ACR do not recommend neuroimaging for patients with primary headache. However, neuroimaging becomes mandatory in presence of red flags to rule out the underlying cause.
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Affiliation(s)
- Aline Camargo
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA
| | - Sangam Kanekar
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA.
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Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method. Life (Basel) 2022; 12:life12020142. [PMID: 35207430 PMCID: PMC8877535 DOI: 10.3390/life12020142] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 01/09/2023] Open
Abstract
Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.
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Merison K, Victorio MCC. Approach to the Diagnosis of Pediatric Headache. Semin Pediatr Neurol 2021; 40:100920. [PMID: 34749917 DOI: 10.1016/j.spen.2021.100920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
Headache in children and adolescents is a common symptom that can be worrisome to patients, their parents and clinicians due to the myriad of underlying etiologies, both benign and life-threatening. The evaluation of headache must be directed primarily to exclude secondary causes. A detailed headache history, recognition of headache patterns and red flags and thorough physical and neurological examinations are essential in the diagnosis; and identifies patients requiring further workup. Considerations for neuroimaging and ancillary testing are also discussed.
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Affiliation(s)
- Kelsey Merison
- NeuroDevelopmental Science Center Akron Children's Hospital, Akron, OH.
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Rosenblum RK, Manion A. An update on practice guidelines for primary care treatment of pediatric migraine. Nurse Pract 2021; 46:18-27. [PMID: 34695047 DOI: 10.1097/01.npr.0000794504.98332.0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Headaches are a frequent reason for children and adolescents to seek healthcare, and such visits include pediatric ED visits. Headache-related school absences can affect academic performance. Diagnosing and treating headaches in this population can be challenging for the primary care NP. This article reviews recent management and treatment guidelines.
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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15
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Abstract
The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.
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16
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Tokatly Latzer I, Orbach R, Ben-Sira L, Mezad-Koursh D, Bachar Zipori A, Roth J, Constantini S, Fattal-Valevski A, Lubetzky R. The Clinical Utility of Inpatient Brain Magnetic Resonance Imaging in Children. J Child Neurol 2020; 35:744-752. [PMID: 32517554 DOI: 10.1177/0883073820931264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical applicability and yield of brain magnetic resonance imaging (MRI) in the setting of an inpatient pediatric department has not been investigated. The authors performed a retrospective chart review of nontraumatic/nonneurosurgical children who underwent brain MRI during their hospitalization in a general pediatric department over a 5-year period. Of the 331 children who underwent brain MRI, 148 (45%) had abnormal findings. High-risk headaches and focal seizures were significantly correlated with findings on brain MRI. Diagnostic and therapeutic yields were most significant in acute demyelinating events, acute cerebrovascular disorders, high-risk headaches when supported by neurologic and ophthalmologic findings, focal seizures with evidence of multifocal epileptic activity on an electroencephalogram and ophthalmic complaints when accompanied by cranial nerve palsy and optic nerve impairment. Since the contributions of a brain MRI in hospitalized children is pivotal in specific clinical situations, a judicious decision-making process should be done before its scheduling, in order to optimize clinical care.
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Affiliation(s)
- Itay Tokatly Latzer
- Pediatric Neurology Institute, 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, 26745Tel-Aviv University, Israel
| | - Rotem Orbach
- Pediatric Neurology Institute, 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, 26745Tel-Aviv University, Israel
| | - Liat Ben-Sira
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Pediatric Radiology Unit, 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Daphna Mezad-Koursh
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Pediatric Ophthalmology Unit, Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Anat Bachar Zipori
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Pediatric Ophthalmology Unit, Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Jonathan Roth
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Department of Pediatric Neurosurgery and 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shlomi Constantini
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Department of Pediatric Neurosurgery and 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, 26745Tel-Aviv University, Israel.,These authors have contributed equally to this work
| | - Ronit Lubetzky
- Sackler School of Medicine, 26745Tel-Aviv University, Israel.,Department of Pediatrics, 108403Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,These authors have contributed equally to this work
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17
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Kadom N. Imaging of Headaches: Appropriateness and Differential Diagnosis. Pediatr Ann 2020; 49:e389-e394. [PMID: 32929514 DOI: 10.3928/19382359-20200819-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Headache is prevalent among children, but practitioners may not be familiar with the numerous clinical and imaging guidelines that intend to foster effective care for children with headaches. Here, the guidelines for imaging used in pediatric headache, including sinus and postconcussive headaches, are summarized. An illustrated discussion of differential considerations for imaging findings in children with secondary headaches is provided and highlights the role imaging plays in their diagnosis. [Pediatr Ann. 2020;49(9):e389-e394.].
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18
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Ahamed SH, Lee KJ, Tang PH. Role of a modified ultrafast MRI brain protocol in clinical paediatric neuroimaging. Clin Radiol 2020; 75:914-920. [PMID: 32782127 DOI: 10.1016/j.crad.2020.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/06/2020] [Indexed: 11/18/2022]
Abstract
AIM To establish a role for modified ultrafast magnetic resonance imaging (MRI) of the brain in clinical paediatric patients based on clinically acceptable image quality and diagnostic accuracy. MATERIALS AND METHODS A prospective study was conducted with institutional review board approval on an ultrafast MRI brain protocol consisting of sagittal T1-weighted, axial T2-weighted, axial fluid-attenuated inversion recovery (FLAIR), axial diffusion-weighted imaging (DWI), and axial T2∗-weighted sequences. Preliminary investigations revealed that the default ultrafast T2-weighted sequence was prone to pulsation artefacts. A modified ultrafast T2-weighted sequence was therefore developed to replace the default ultrafast T2-weighted sequence. Thirty-five patients with clinical indication for neuroimaging underwent ultrafast MRI, modified ultrafast T2-weighted sequence and standard MRI at 3 T. Image quality of ultrafast MRI sequences were graded as clinically "diagnostic" or "non-diagnostic" and compared against the corresponding standard MRI sequences as the reference standard. The modified ultrafast T2-weighted sequence surpassed the default ultrafast T2-weighted sequence in image quality. The ultrafast MRI protocol was therefore replaced with the modified ultrafast T2-weighted sequence creating a modified ultrafast MRI protocol. The clinical reports of modified ultrafast MRI were compared against standard MRI for diagnostic concordance, categorised further as "normal", "clinically significant", or "clinically minor" abnormalities. RESULTS Ultrafast T1-weighted, FLAIR, and DWI sequences had comparable image quality to standard MRI sequences. The ultrafast T2∗-weighted sequence had significantly higher non-diagnostic images (42.9%) compared to the standard MRI sequence (2.9%). The default ultrafast T2-weighted sequence had significantly higher non-diagnostic images compared to the modified ultrafast T2-weighted sequence and standard T2-weighted sequence (82.9%, 5.7%, 8.6%, respectively). There was 100% concordance for normal and clinically significant abnormalities and 23% discordance for clinically minor abnormalities. Modified ultrafast MRI takes 5 minutes 41 seconds compared to standard MRI time of 14 minutes 57 seconds. CONCLUSION The modified ultrafast MRI protocol for brain imaging demonstrates clinically acceptable image quality in four out of five sequences and has high accuracy in diagnosing normal and clinically significant abnormalities when compared against the standard MRI protocol for brain imaging. It could potentially benefit a select group of paediatric patients who require neuroimaging.
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Affiliation(s)
- S H Ahamed
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore.
| | - K J Lee
- Singapore Bioimaging Consortium, Agency for Science, Technology and Research (A∗STAR), 11 Biopolis Way, #02-02 Helios, 138667, Singapore
| | - P H Tang
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore
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19
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Tsze DS, Cruz AT, Mistry RD, Gonzalez AE, Ochs JB, Richer L, Kuppermann N, Dayan PS. Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches. J Pediatr 2020; 221:207-214. [PMID: 32446483 PMCID: PMC7251971 DOI: 10.1016/j.jpeds.2020.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches. STUDY DESIGN We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables. RESULTS We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate. CONCLUSIONS A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine. Houston, TX
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine. Aurora, CO
| | - Ariana E. Gonzalez
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Julie B. Ochs
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta. Edmonton, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine. Sacramento, CA
| | - Peter S. Dayan
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
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20
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Imaging Utilization in Children With Headaches: Current Status and Opportunities for Improvement. J Am Coll Radiol 2020; 17:574-583. [DOI: 10.1016/j.jacr.2020.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 02/08/2023]
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22
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Raucci U, Della Vecchia N, Ossella C, Paolino MC, Villa MP, Reale A, Parisi P. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol 2019; 10:886. [PMID: 31507509 PMCID: PMC6716213 DOI: 10.3389/fneur.2019.00886] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 07/30/2019] [Indexed: 12/16/2022] Open
Abstract
Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Della Vecchia
- Department of Pediatrics, University of "Studi della Campania Luigi Vanvitelli", Naples, Italy
| | - Chiara Ossella
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Chiara Paolino
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Antonino Reale
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
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23
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Abstract
OBJECTIVE. The purposes of this article are to describe implementation of an abbreviated brain MRI protocol for use in children with primary headache and to present an experience with the adaptation of the protocol in practice, work flow integration, and effects on sedation use. CONCLUSION. The abbreviated brain MRI protocol reduced the need for sedation for 74% of the study sample. Use of this protocol in this particular patient population continues, but further validation is required before its use is expanded to other pediatric populations.
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