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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; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [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] [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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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. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [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: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), 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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Phelps K, Silos C, De La Torre S, Moreno A, Lapus R, Sanghani N, Koenig M, Savitz S, Green C, Fraser S. Establishing a pediatric acute stroke protocol: experience of a new pediatric stroke program and predictors of acute stroke. Front Neurol 2023; 14:1194990. [PMID: 37273694 PMCID: PMC10232855 DOI: 10.3389/fneur.2023.1194990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Pediatric stroke is among the top 10 causes of death in pediatrics. Rapid recognition and treatment can improve outcomes in select patients, as evidenced by recent retrospective studies in pediatric thrombectomy. We established a collaborative protocol involving the vascular neurology and pediatric neurology division in our institution to rapidly diagnose and treat pediatric suspected stroke. We also prospectively collected data to attempt to identify predictors of acute stroke in pediatric patients. Methods IRB approval was obtained to prospectively collect clinical data on pediatric code stroke activations based on timing metrics in resident-physician note templates. The protocol emphasized magnetic resonance imaging over computed tomography imaging when possible. We analyzed performance of the system with descriptive statistics. We then performed a Bayesian statistical analysis to search for predictors of pediatric stroke. Results There were 40 pediatric code strokes over the 2.5-year study period with a median age of 10.8 years old. 12 (30%) of patients had stroke, and 28 (70%) of code stroke patients were diagnosed with a stroke mimic. Median time from code stroke activation to completion of imaging confirming or ruling out stroke was 1 h. In the Bayesian analysis, altered mental status, hemiparesis, and vasculopathy history were associated with increased odds of stroke, though credible intervals were wide due to the small sample size. Conclusion A trainee developed and initiated pediatric acute stroke protocol quickly implemented a hospital wide change in management that led to rapid diagnosis and triage of pediatric stroke and suspected stroke. No additional personnel or resources were needed for this change, and we encourage other hospitals and emergency departments to implement similar systems. Additionally, hemiparesis and altered mental status were predictors of stroke for pediatric acute stroke activation in our Bayesian statistical analysis. However credible intervals were wide due to the small sample size. Further multicenter data collection could more definitively analyze predictors of stroke, as well as the help in the creation of diagnostic tools for clinicians in the emergency setting.
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Affiliation(s)
- Kamal Phelps
- University of Texas McGovern Medical School, Houston, TX, United States
| | - Christin Silos
- School of Biomedical Informatics, The University of Texas Health Science Center Houston, Houston, TX, United States
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Susan De La Torre
- Department of Internal Medicine, University of Illinois College of Medicine, Chicago, IL, United States
| | - Amee Moreno
- Baylor University Louise Herrington School of Nursing, Dallas, TX, United States
| | - Robert Lapus
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Nipa Sanghani
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Mary Koenig
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Sean Savitz
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Charles Green
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Stuart Fraser
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
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Troy L, Burch M, Sawicki JG, Henricksen JW. Pediatric rapid response system innovations. Hosp Pract (1995) 2021; 49:399-404. [PMID: 35012417 DOI: 10.1080/21548331.2022.2028468] [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: 07/06/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
Rapid Response Systems (RRSs) are an organizational approach to support the timely recognition and treatment of decompensating patients and are used in many pediatric hospitals. These systems are comprised of afferent and efferent Limbs, as well as oversight arms. When incorporated into an RRS, standardized care algorithms can be helpful in identifying deteriorating patients and improving behaviors of the multidisciplinary team. The aim of this paper is to provide an overview of pediatric RRS and provide an example in which standardized care algorithms developed for the efferent limb of a pediatric RRS were associated with improvement in early escalation of care.PLAIN LANGUAGE SUMMARYThe Rapid Response System (RRS) is used in hospitals to recognize and care for hospitalized patients that are decompensating outside of an Intensive Care Unit. RRSs are made up of two main response components. The afferent limb focuses on the recognition and calls for help; the efferent limb focuses on correcting the deteriorating patient's physiology. Much energy has been put into afferent limb development to identify worsening patients before they progress to full cardiac or respiratory arrest. Standardization of efferent limb care algorithms can assist in developing and maintaining a shared mental model of care to improve communication and function of the multidisciplinary team.
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Affiliation(s)
- Lindsey Troy
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mary Burch
- Department of Nursing Excellence, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jonathan G Sawicki
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jared W Henricksen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Filatov A, Alvarez J, Seibert J, Swerdloff M. Management of Pediatric Strokes With Alteplase (Tissue Plasminogen Activator). Cureus 2021; 13:e17088. [PMID: 34527475 PMCID: PMC8431982 DOI: 10.7759/cureus.17088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/10/2021] [Indexed: 01/01/2023] Open
Abstract
In the pediatric population, ischemic stroke is rare. Pediatric patients with acute ischemic stroke are eligible for intravenous thrombolysis and/or mechanical thrombectomy. However, due to the rare occurrence of strokes and national shortage of pediatric neurologists, timely diagnosis and appropriate treatment can be challenging. We report a case of a 16-year-old female who presented with an acute ischemic stroke to our adult comprehensive stroke program.
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Affiliation(s)
- Asia Filatov
- Neurology, Florida Atlantic University, Boca Raton, USA
| | - Jaime Alvarez
- Emergency Medicine, Boca Raton Regional Hospital, Boca Raton, USA
| | | | - Marc Swerdloff
- Neurology, Marcus Neuroscience Institute, Boca Raton, USA
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Keskin H, Keskin F, Tavaci T, Halici H, Yuksel TN, Ozkaraca M, Bilen A, Halici Z. Neuroprotective effect of roflumilast under cerebral ischaemia/reperfusion injury in juvenile rats through NLRP-mediated inflammatory response inhibition. Clin Exp Pharmacol Physiol 2021; 48:1103-1110. [PMID: 33686709 DOI: 10.1111/1440-1681.13493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/24/2022]
Abstract
This study aims to investigate the protective effect of roflumilast, a phosphodiesterase (PDE)-4 enzyme inhibitor, and demonstrate its possible role in the development prevention of cerebral ischemia/reperfusion injury (CI/RI) after stroke induced by carotid artery ligation in juvenile rats. The rats were randomly divided into five groups: healthy group without any treatment, healthy group administered with 1 mg/kg roflumilast, CI group not administered with roflumilast, CI group administered with 0.5 mg/kg roflumilast, and CI group administered with 1 mg/kg roflumilast. In the CI groups, reperfusion was achieved 2h after ischemia induction; in the roflumilast groups, this drug was intraperitoneally administered immediately after reperfusion and at the 12th hour. At the end of 24h, the rats were sacrificed and their brain tissues removed for examination. The mRNA expressions obtained with real-time PCR of IL-1β, TNF-α, and NLRP3 significantly increased in the CI/RI-induced groups compared with the control group, and this increase was significantly lower in the groups administered with roflumilast compared with the CI/RI-induced groups. Moreover, ELISA revealed that both IL-1 β and IL-6 brain levels were significantly higher in the CI/RI-induced groups than in the controls. This increase was significantly lower in the groups administered with roflumilast compared with the CI/RI-induced groups. Histopathological studies revealed that the values closest to those of the healthy group were obtained from the roflumilast groups. Nissl staining revealed that the Nissl bodies manifested normal density in the healthy and roflumilast-administered healthy groups, but were rare in the CI/RI-induced groups. Roflumilast treatment increased these decreased Nissl bodies with increasing doses. Observations indicated that the Nissl body density was close to the value in the healthy group in the CI/RI-induced group administered with 1 mg/kg roflumilast. Overall, roflumilast reduced cellular damage caused by CI/RI in juvenile rats, and this effect may be mediated by NLRP3.
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Affiliation(s)
- Halil Keskin
- Division of Paediatric Intensive Care Unit, Department of Paediatrics, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Filiz Keskin
- Division of Paediatric Neurology, Department of Paediatrics, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Taha Tavaci
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Hamza Halici
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Tugba Nurcan Yuksel
- Department of Pharmacology, Namik Kemal University Faculty of Medicine, Tekirdag, Turkey
| | - Mustafa Ozkaraca
- Department of Pathology, Cumhuriyet University Faculty of Veterinary, Sivas, Turkey
| | - Arzu Bilen
- Division of Endocrinology, Department of Internal Medicine, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Zekai Halici
- Department of Pharmacology, Ataturk University Faculty of Medicine, Erzurum, Turkey
- Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
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Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management. CHILDREN 2021; 8:children8080649. [PMID: 34438540 PMCID: PMC8394345 DOI: 10.3390/children8080649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/05/2023]
Abstract
Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.
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Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1578-1586. [PMID: 33392566 PMCID: PMC7771757 DOI: 10.1002/emp2.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023] Open
Abstract
Strokes are more commonly seen in adults but also occur in the pediatric population. Similar to adult strokes, pediatric strokes are considered medical emergencies and require prompt diagnosis and treatment to maximize favorable outcomes. Unfortunately, the diagnosis of stroke in children is often delayed, commonly because of parental delay or failure to consider stroke in the differential diagnosis. Children, especially young children, often present differently than adults. Much of the treatment for pediatric strokes has been adapted from adult guidelines but the optimal treatment has not been clearly defined. In this article, we review pediatric strokes and the most recent recommendations for treatment.
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Affiliation(s)
- Michael D. Baldovsky
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Pamela J. Okada
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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Oziel M, Korenstein R, Rubinsky B. A Brain Phantom Study of a Noncontact Single Inductive Coil Device and the Attendant Algorithm for First Stage Diagnosis of Internal Bleeding in the Head. J Med Device 2020. [DOI: 10.1115/1.4045489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Hemorrhagic stroke is one of the leading causes of premature death among economically disadvantaged populations. Treatments of these conditions require an early diagnosis. While computed tomography and magnetic resonance imaging are the medical gold standard for early diagnosis, these imaging modalities are rarely available in low- and middle-income countries. We present an unsophisticated noncontact single coil inductive device and a simple algorithm for detection of changes in fluid/tissue ratio in the head which simulates blood vessel bursting in the brain. Experiments were performed on a typical phantom model of the head and internal bleeding was simulated by injection of physiological saline at two locations in the head phantom. The primary motivation for this work is the need for a simple and robust detection device and algorithm for diagnosis of hemorrhagic stroke in low- and middle-income countries. This phantom-based study shows that the technology and in particular the algorithm introduced here are robust and could replace conventional imaging for first stage diagnosis of internal bleeding in the head, and thereby save millions of lives every year. Clinical studies are required to further examine the technology and the algorithm.
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Affiliation(s)
- Moshe Oziel
- Department of Physiology and Pharmacology, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Rafi Korenstein
- Department of Physiology and Pharmacology, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Boris Rubinsky
- Department of Mechanical Engineering, University of California Berkeley, Berkeley, CA 94720
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10
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Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities. Rev Neurol (Paris) 2020; 176:20-29. [DOI: 10.1016/j.neurol.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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Sherman V, Greco E, Moharir M, Beal D, Thorpe K, Martino R. Feeding and swallowing impairment in children with stroke and unilateral cerebral palsy: a systematic review. Dev Med Child Neurol 2019; 61:761-769. [PMID: 30411334 DOI: 10.1111/dmcn.14094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 01/12/2023]
Abstract
AIM This systematic review targeted frequency estimates of dysphagia (feeding and swallowing problems), related health outcomes, and caregiver burden in children with stroke or unilateral cerebral palsy (CP). METHOD Six electronic databases were searched from their inception to November 2017 along with a manual search of eight relevant journals. Two blinded raters assessed abstracts and full articles for eligibility. Discrepancies were resolved by consensus. Accepted articles were evaluated for quality. Data were extracted and analysed descriptively. RESULTS Of 1660 abstracts, five met inclusion criteria, of which three focused on stroke and two unilateral CP. Across studies, operational definitions of feeding and swallowing varied. Insufficient details were provided on assessment methods and timing. Reported frequencies of dysphagia ranged from 24.2% to 88.6%. One study reported dysphagia-related health outcomes and none reported caregiver burden. INTERPRETATION These results suggest that dysphagia is common in children with stroke and unilateral CP; however, its frequency is yet unknown as is its impact on health and caregiver burden. Availability of a standardized tool to identify dysphagia in these children accurately is a recommended first step to address this evidence gap. WHAT THIS PAPER ADDS There is limited data on the incidence of dysphagia after childhood stroke and unilateral cerebral palsy. Available evidence shows reported dysphagia frequencies from 24.2% to 88.6%. Only one study reported on dysphagia-related health outcomes. No study reported on caregiver burden.
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Affiliation(s)
- Victoria Sherman
- Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Science Institute, University of Toronto, Toronto, Ontario, Canada
| | - Elissa Greco
- Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Science Institute, University of Toronto, Toronto, Ontario, Canada
| | - Mahendranath Moharir
- Pediatric Stroke Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deryk Beal
- Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Science Institute, University of Toronto, Toronto, Ontario, Canada.,Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Kevin Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Applied Health Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rosemary Martino
- Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Science Institute, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
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Abstract
Pediatric stroke is relatively rare, with approximately 1000 childhood strokes in the United States per year. However, the occurrence of stroke in children leads to significant morbidity and mortality, warranting the development proven screening tools, protocols, and treatment options. Because significant delays in seeking medical attention can occur, time to recognition of pediatric stroke in the emergency department is uniquely challenging and critical. Once recognized, a trained multidisciplinary team with a multifaceted approach is needed to provide the best possible outcome for the patient. Key elements of the pediatric stroke protocol should include recognition tools, stroke alert mechanism, stroke order sets, timely imaging, laboratory evaluation, and treatment options. Substantial advancements have been made in the field of pediatric stroke protocols mainly due to formation of international consortiums and clinical trial. Despite significant progress, treatment options remain controversial.
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Abstract
PURPOSE OF REVIEW All critical care is directed at maintaining brain health, but recognizing neurologic complications of critical illness in children is difficult, and limited data exist to guide practice. This article discusses an approach to the recognition and management of seizures, stroke, and cardiac arrest as complications of other critical illnesses in the pediatric intensive care unit. RECENT FINDINGS Convulsive and nonconvulsive seizures occur frequently in children after cardiac arrest or traumatic brain injury and during extracorporeal membrane oxygenation. Seizures may add to neurologic morbidity, and continuous EEG monitoring is needed for up to 24 hours for detection. Hypothermia has not been shown to improve outcome after cardiac arrest in children, but targeted temperature management with controlled normothermia and prevention of fever is a mainstay of neuroprotection. SUMMARY Much of brain-directed pediatric critical care is empiric. Recognition of neurologic complications of critical illness requires multidisciplinary care, serial neurologic examinations, and an appreciation for the multiple risk factors for neurologic injury present in most patients in the pediatric intensive care unit. Through attention to the fundamentals of neuroprotection, including maintaining or restoring cerebral perfusion matched to the metabolic needs of the brain, combined with anticipatory planning, these complications can be prevented or the neurologic injury mitigated.
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Klucka J, Stourac P, Stoudek R, Toukalkova M, Harazim H, Kosinova M, Stouracova A, Mrlian A, Suk P, Malaska J. Ischemic stroke in paediatrics - narrative review of the literature and two cases. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:24-30. [DOI: 10.5507/bp.2016.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/11/2016] [Indexed: 12/30/2022] Open
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Abstract
PURPOSE OF REVIEW Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
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DeLaroche AM, Sivaswamy L, Farooqi A, Kannikeswaran N. Pediatric Stroke Clinical Pathway Improves the Time to Diagnosis in an Emergency Department. Pediatr Neurol 2016; 65:39-44. [PMID: 27743748 DOI: 10.1016/j.pediatrneurol.2016.09.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Identified barriers to the diagnosis of pediatric stroke include delays in provider recognition and definitive neuroimaging (magnetic resonance imaging). Clinical pathways are recommended to address these barriers; yet few studies have evaluated their impact. Our aim is to describe the effect of a pediatric stroke clinical pathway on the diagnosis of stroke in patients presenting with focal neurological dysfunction to a pediatric emergency department. METHODS The pediatric stroke clinical pathway was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. Demographic and clinical data were collected for patients ultimately diagnosed with stroke using the pediatric stroke clinical pathway and compared with data collected on patients diagnosed with stroke before implementation of the pediatric stroke clinical pathway. RESULTS The pediatric stroke clinical pathway was activated for 36 patients. Stroke was diagnosed in 11 patients (33%), of whom 55% were male with a median age 11 ± 7 years. Focal deficits (82%) and headache (55%) were common presenting complaints. There was a significant improvement in the median time to magnetic resonance imaging from arrival to the emergency department (before implementation of the pediatric stroke clinical pathway: 17 hours [interquartile range 6, 22] versus after implementation of the pediatric stroke clinical pathway: four hours [interquartile range 3, 12]; P = 0.02). CONCLUSIONS The pediatric stroke clinical pathway improved time to definitive diagnosis and streamlined the care provided to children presenting to the pediatric emergency department with focal neurological dysfunction.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
| | - Lalitha Sivaswamy
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- Department of Pediatrics, Children's Research Center of Michigan, School of Medicine, Wayne State University, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Simon E, Long B, Koyfman A. Emergency Medicine Management of Sickle Cell Disease Complications: An Evidence-Based Update. J Emerg Med 2016; 51:370-381. [DOI: 10.1016/j.jemermed.2016.05.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/12/2016] [Accepted: 05/17/2016] [Indexed: 01/30/2023]
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Chabrier S, Kossorotoff M, Husson B, Saliou G. Paediatric neurothrombectomy: Time is (childhood) brain or First, do no harm? Eur J Paediatr Neurol 2016; 20:795-6. [PMID: 27235193 DOI: 10.1016/j.ejpn.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Stéphane Chabrier
- Centre National de Référence de l'AVC de l'Enfant, Saint-Étienne & Paris, France.
| | - Manoëlle Kossorotoff
- Centre National de Référence de l'AVC de l'Enfant, Saint-Étienne & Paris, France
| | - Béatrice Husson
- Centre National de Référence de l'AVC de l'Enfant, Saint-Étienne & Paris, France
| | - Guillaume Saliou
- Centre National de Référence de l'AVC de l'Enfant, Saint-Étienne & Paris, France
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