Pedi Headache

[EmergencyMedicalTigger]

Just thought I would throw this out there to see if any of you more experienced medics have any ideas on this. Of course I would get this call after a crappy week of running codes every shift, having a crappy birthday this weekend, and just generally not wanting to be here this morning.

Dispatched to an 11 yo male having headaches x 3 days. AOSTF patient laying in parents' bed screaming b/c fire department had just poked his finger for a glucose check. BGL=187. Hx-ADHD and currently no meds, NKA. Patient started c/o bad headache Thursday, woke up this morning completely disoriented. He would not follow commands or respond appropriately to parents-just walked around the house. When we would stop touching him, he would calm down and become compliant enough that he walked himself to the stretcher. NSR on monitor. Slightly brady on 12-lead (55 bpm), but did not raise concern as he was a very fit 11 yo. He would c/o pain one moment and then not have pain several miutes later. When I would stop talking to him or touching him, he would become lethargic. I was prepared for him to be a little combative, but he completely freaked out when I went to start the IV to the point of trying to grab the needle out of my hand. I said forget it, had my partner upgrade to emergency traffic and just got him to the hospital. His bp remained stable about 120/70 the whole time. The remainder of transport he screamed anytime I would say something. PEARL,mom denies drugs/meds, trauma, sickle cell, fever, neck pain, or any illness other than headache.

My guess was meningitis, my partner thought a tumor. I've seen a good number of psyc patients and violent drug addicts, but this kid was about as close to possessed as I've come across. It took 4ml of Ativan to calm him just so we could leave and not have to help restrain him. He started screaming again after we left, think they were doing a foley. I found out from the hospital he was transferred to Tx Children's with encephalitis. He did not test positive for meningitis. My best friend works at Tx Children's and did an xray on him this afternoon. He's in ICU, intubated, restrained, and posturing from the consistent seizures. They haven't found a reason for the continued swelling in his brain. Anyone run into something similar? I'm completely baffled and in shock that my disoriented, ambulatory patient might now become a vegetable if he survives and he had no symptoms or than disorientation and an unexplained headache.

[island emt]

My guess was meningitis, my partner thought a tumor. I've seen a good number of psyc patients and violent drug addicts, but this kid was about as close to possessed as I've come across. It took 4ml of Ativan to calm him just so we could leave and not have to help restrain him. He started screaming again after we left, think they were doing a foley. I found out from the hospital he was transferred to Tx Children's with encephalitis. He did not test positive for meningitis. My best friend works at Tx Children's and did an xray on him this afternoon. He's in ICU, intubated, restrained, and posturing from the consistent seizures. They haven't found a reason for the continued swelling in his brain. Anyone run into something similar? I'm completely baffled and in shock that my disoriented, ambulatory patient might now become a vegetable if he survives and he had no symptoms or than disorientation and an unexplained headache.

Don't know about your area but we have had several cases of EEE [eastern equine encephalitis] This year. It is a mosquito borne virus. Some of these cases are mild & some have resulted in death. There are many different viral causes such as mumps, measles, Herpes zoster, chicken pox. IT is thought that with some areas having lower immunization rates in younger children that this will cause localized outbreaks that are completely avoidable by proper immunizations.

Here are a few S&S.

Signs and Symptoms

Symptoms in milder cases of encephalitis usually include:

fever

headache

poor appetite

loss of energy

a general sick feeling

In more severe cases of encephalitis, a person is more likely to experience high fever and any of a number of symptoms that relate to the central nervous system, including:

severe headache

nausea and vomiting

stiff neck

confusion

disorientation

personality changes

convulsions (seizures)

problems with speech or hearing

hallucinations

memory loss

drowsiness

coma

[mobey]

Hmmm...... encephalitis in absence of infection or hyperglycemia hey?

Can't say I have any DD for ya, but I would suspect there is an infection undiagnosed, or unrevieled to you. epstein-Barr comes to mind, but of course meningitis was first. Did the child have all his vaccinations?

Temp?

Side note: One thing that came to mind was maybe the headache was secondary to tinitis from ASA OD.... as I was reading I thought that was where this was gonna go..... obvioustly not the case, but I wanted to type it for my own benefits.

[EmergencyMedicalTigger]

Hmmm...... encephalitis in absence of infection or hyperglycemia hey?

Can't say I have any DD for ya, but I would suspect there is an infection undiagnosed, or unrevieled to you. epstein-Barr comes to mind, but of course meningitis was first. Did the child have all his vaccinations?

Temp?

Side note: One thing that came to mind was maybe the headache was secondary to tinitis from ASA OD.... as I was reading I thought that was where this was gonna go..... obvioustly not the case, but I wanted to type it for my own benefits.

The only thing I could come up with might be west nile. He was current on vaccinations. Temp was normal according to mom. I couldn't take one b/c of how combative he was. I could've tried, but it wouldn't have been very accurate.

[HERBIE1]

I like some type of encephalitis, w/ the edema, but...

Poisoning of some type- could explain the symptoms? Accidental/intentional prescription drug ingestion? Amy meds in the house?

[EmergencyMedicalTigger]

I like some type of encephalitis, w/ the edema, but...

Poisoning of some type- could explain the symptoms? Accidental/intentional prescription drug ingestion? Amy meds in the house?

As we all know, family and patients tend to lie or be in denial, ie, "my baby wouldn't do that." The mom seemed pretty sincere that he hadn't taken anything intentionally. Even as far as recreational drugs, she stated he didn't have very many friends, was a loner, and was not likely to be taking drugs.

I'm going to try and find out what his status is in the morning.

[Dustdevil]

Wow... serious run. One to remember every time some blowhard starts whining about the headache calls.

Sounds like you and your partner did a great job of immediately narrowing it down to the two most significant differentials. The relatively short onset weighs in favour of your diagnosis, but a tumour, bleed, or AVM are certainly possibilities to be considered, so your partner was on the right track. Our immediate treatment would not differ either way, so the plan was appropriate.

Thanks for the review!

[scubanurse]

That's a scary call!!! On a different note from DD and causes...make sure you and your partner talk about it either with each other or someone else. Calls like these have a way of catching up to you later with CISM. I know the horse is dead on CISM and how to deal with it, but just keep an eye out for each other as calls like this do have a tendency to still bug you over time.

[EmergencyMedicalTigger]

The latest update for anyone wondering...He's still in ICU basically in a coma. No menigitis found after multiple tests. Comments in his notes made referencing encephalitis due to unk chemical intoxication. Initially I questioned the mom pretty hard about meds or drugs. My partner blew it off, I think b/c of the pt's age. It just goes to show you how much things have changed since not even 10 or 20 years ago. Kids are getting involved in bad things alot younger.

[Kaisu]

The latest update for anyone wondering...He's still in ICU basically in a coma. No menigitis found after multiple tests. Comments in his notes made referencing encephalitis due to unk chemical intoxication. Initially I questioned the mom pretty hard about meds or drugs. My partner blew it off, I think b/c of the pt's age. It just goes to show you how much things have changed since not even 10 or 20 years ago. Kids are getting involved in bad things alot younger.

So sad. Thank you for the update