RESUMEN
A 14-year-old previously healthy female was transferred from a local emergency department after being found unresponsive at home. Parental questioning revealed she had fever and pharyngitis 2 weeks before presentation. Past mental health history was negative, including concern for past or present suicidal ideation/attempts, suspected substance use, or toxic ingestion. In the emergency department, she was orotracheally intubated due to a Glasgow Coma Scale of 3. She was hemodynamically stable and euglycemic. Electrocardiogram showed sinus tachycardia. She underwent a noncontrast head computed tomography that was normal and subsequently underwent a lumbar puncture. She had a seizure and was given a loading dose of diazepam and fosphenytoin that led to cessation of extremity movements. She was subsequently transferred to the PICU for additional evaluation. Initial examination without sedation or analgesia demonstrated dilated and minimally responsive pupils, intermittent decorticate posturing, and bilateral lower extremity rigidity and clonus, consistent with a Glasgow Coma Scale of 5. Serum studies were unremarkable with the exception of mild leukocytosis. Chest radiograph only showed atelectasis. She was empirically started on antibiotics to cover for meningitis pending final cerebral spinal fluid test results. The pediatric neurology team was consulted for EEG monitoring, and the patient was eventually sent for computed tomography angiogram and magnetic resonance angiogram/venogram. We will review diagnostic evaluation and management of an adolescent patient with acute encephalopathy with decorticate posturing of unclear etiology.
Asunto(s)
Encefalopatía Aguda Febril/inducido químicamente , Encefalopatía Aguda Febril/etiología , Encefalopatía Aguda Febril/terapia , Amitriptilina/análogos & derivados , Bupropión/toxicidad , Estado de Descerebración/inducido químicamente , Estado de Descerebración/etiología , Síndrome de la Serotonina/diagnóstico , Intento de Suicidio , Clorhidrato de Venlafaxina/toxicidad , Encefalopatía Aguda Febril/diagnóstico por imagen , Adolescente , Amitriptilina/toxicidad , Encéfalo/diagnóstico por imagen , Estado de Descerebración/diagnóstico por imagen , Diagnóstico Diferencial , Servicio de Urgencia en Hospital , Femenino , Escala de Coma de Glasgow , Humanos , Unidades de Cuidado Intensivo Pediátrico , Comunicación Interdisciplinaria , Colaboración Intersectorial , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Automedicación , Intento de Suicidio/prevención & control , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Research on the safety and efficacy of continuous lidocaine infusions (CLIs) for the treatment of pain in the pediatric setting is limited. This article describes a series of pediatric oncology patients who received lidocaine infusions for refractory, longstanding, cancer-related pain. PROCEDURE: This is a retrospective review of patients who underwent lidocaine infusions to manage severe, opioid-refractory, cancer-related pain. Four patients ranging in age from 8 to 18 years were admitted to a pediatric hospital for their medical conditions and/or pain management. Structured chart review established demographic and diagnosis information, infusion rates, side effects, and efficacy of infusions in providing pain relief. Lidocaine bolus doses, infusion rates, serum concentrations, and subjective pain scores were analyzed. RESULTS: Median pain scores prior to lidocaine infusions were 8/10, falling to 2/10 at the infusion termination (P < 0.003), and rising to 3/10 in the first 24 hr after lidocaine (P < 0.029 compared to preinfusion pain). The infusions were generally well tolerated, with few side effects noted. In most cases, the improvement in pain scores persisted beyond termination of the infusion. CONCLUSIONS: CLIs were a helpful adjuvant in the four cases presented and may be an effective therapy for a more diverse array of refractory cancer pain. The majority of patients experienced pain relief well beyond the metabolic elimination of the lidocaine, corroborating a modulation effect on pain windup. Additional research regarding infusion rates, serum concentrations, side effects, and outpatient follow-up in a larger group of patients will provide additional insight into the role and safety of this therapy in children.