Epidemiologic findings of cancer detected in a pediatric emergency department

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol

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.

Pediatric Hematologic and Oncologic Emergencies

Pediatric hematologic and oncologic emergencies are in 3 major categories: complications of hematologic disorders, emergencies associated with the new onset of cancers, and treatment-associated oncologic emergencies. The overall number of these patients remains low; however, the mortality associated with these diseases remains high despite significant advances in management. This article presents a review of the most commonly encountered pediatric hematologic and oncologic complications that emergency physicians and providers need to know.

Abdominal Lymphoma Presenting as Terminal Ileitis: A Case Report

BACKGROUND

Most pediatric patients with lymphoma do not have classic symptoms of fever, night sweats, and weight loss. Lymphoma can present as vague symptoms and may mimic common pediatric abdominal emergencies. In this case report, we present a child who presented with abdominal pain and who was initially misdiagnosed as having a surgical emergency.

CASE REPORT

An 11-year-old previously healthy male was referred to the pediatric emergency department after he presented to an outside hospital with 3 days of right lower quadrant pain and 1 episode of diarrhea. The initial concern was appendicitis. He had a computed tomography scan of the abdomen and pelvis that showed thickening of the bowel wall, peritoneal thickening, and a right pleural effusion. His laboratory assessments were only notable for a mildly elevated lactate dehydrogenase level of 506 units/L. He had a colonoscopy, and biopsy specimens obtained from the terminal ileum and cecum were negative. He developed worsening symptoms, and subsequently underwent laparoscopic biopsy procedures of the omentum and terminal ileum, which were consistent with Burkitt lymphoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss the important oncologic findings of pediatric lymphoma, including oncologic emergencies and important laboratory and imaging tests that providers should consider while in the emergency department. This case highlights how pediatric lymphoma can mimic common pediatric pathologies providers often encounter in the emergency department.

Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging

BACKGROUND

Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging.

OBJECTIVES

We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population.

METHODS

A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities.

RESULTS

We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging.

CONCLUSIONS

Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.

Presenting symptoms of pediatric brain tumors diagnosed in the emergency department

OBJECTIVE

The primary objective of this study is to categorize the symptoms associated with brain tumors as diagnosed in the emergency department (ED). The secondary objective is to detail the specific characteristics of these headaches via a subgroup analysis.

METHODS

A retrospective chart review was performed among patients younger than 18 years presenting to a large urban tertiary care facility. Electronic medical records were searched and reviewed from 2002 to 2011 for inpatient discharge diagnoses using malignant and benign central nervous system tumor International Classification of Diseases, Ninth Revision codes.

RESULTS

The electronic records of ED visits for 87 patients were reviewed. The most frequent signs and symptoms were as follows: headache (66.7%), hydrocephalus (58.6%), nausea/vomiting (49.4%), gait disturbance (42.5%), vision changes (20.7%), seizure (17.2%), behavior/school change (17.2%), cranial nerve deficits (16.1%), altered mental status (16.1%), back/neck pain (16.1%), papilledema (12.6%), facial asymmetry (10.3%), sensory deficits (8.0%), focal motor weakness (6.9%), cranial nerve 6 deficit (6.9%), ptosis (5.7%), macrocephaly (4.6%), asymptomatic (3.4%), and anisocoria (1.1%). The frequencies of location of headache were diffuse (24.1%), frontal (12.1%), occipital (8.6%), and parietal/temporal (6.9%). The severity was described as severe (37.9%) followed by moderate and mild (10.3% and 5.2%, respectively). Most headaches occurred in the morning (13.8%) and night (12.1%), and their quality was predominantly progressively worsening (50.0%)

CONCLUSIONS

Brain tumors diagnosed in the ED most commonly present with headache, hydrocephalus, nausea/vomiting, and gate disturbances. The headaches are described as progressively worsening and diffuse most commonly occurring in the morning and night.