BIG Kids: Application of a modified brain injury guideline in a pediatric trauma center.

BACKGROUND: Brain Injury Guidelines (BIG) were developed to stratify traumatic brain injuries (TBIs) by severity to decrease unnecessary CT imaging and neurosurgical consultation in low-risk cases. This study evaluated the potential effect of a modified pediatric BIG (pBIG) algorithm would have on resource utilization. METHODS: Isolated TBIs (<18 years) were queried from our Pediatric Trauma Registry from 2017 to 2020. Injuries were classified as mild (pBIG 1), moderate (pBIG 2), or severe (pBIG 3) based on neurologic status, skull fractures, size, and the number of bleeds. Modifications from the institutional adult algorithm were upgrading <4 mm epidural hematomas to pBIG 2 and eliminating interfacility transfer as a pBIG 2 criteria. The proposed pBIG 1 and 2 care plans do not include routine repeat CTs or neurosurgical consultation. RESULTS: A total of 314 children with a mean age of 4.9 years were included. Skull fractures (213, 68%) and subdural hematomas (162, 52%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG 1, 26 (25%) pBIG 2, 61 (34%) pBIG 3). Neurosurgical consultation was obtained in 306 (98%), with 50 (16%) requiring intervention (1 (1%) pBIG 2 and 49 (27%) pBIG 3). Following the proposed pBIG would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%). Following the algorithm, 91 (29%) kids would have been admitted to a higher level of care and 45 (14.3%) to a lower level. CONCLUSIONS: Implementation of our pBIG algorithm would decrease neurosurgery consults (40% reduction) and repeat head CTs (29% reduction).

Severe liver dysfunction in a toddler receiving nonprescription phytocannabinoid.

BACKGROUND: Nonprescription cannabis products are becoming widely available and being promoted for various health conditions. Safety profile of these products apart from psychoactive effects has not been studied and published well. Liver dysfunction is well described in literature with high doses of recreational tetrahydrocannabinol and cannabidiol products but not with nonprescription phytocannabinoids products used for various medicinal values. CASE SUMMARY: A 2-year-old unimmunized male with infantile spasms and refractory seizures, managed with clobazam and zonisamide, presented for respiratory illness and incidentally diagnosed with severe liver dysfunction with elevated coagulation markers. He did not manifest any clinical signs of liver failure. On further review, it was found that parents were using nonprescription phytocannabinoids (hemp extract) for his neurological condition. He required supportive care for his liver dysfunction, and liver enzymes down trended gradually after holding his phytocannabinoid products. The World Health Organization-Uppsala Monitoring Centre approach puts the presentation as probable/likely category of adverse reaction for liver dysfunction with phytocannabinoid ingestion. PRACTICAL IMPLICATIONS: The case we present shows the detrimental effects of over-the-counter phytocannabinoid products, which could point toward the role of phytocannabinoids in this pathophysiology. The case highlights the importance of awareness of potential life-threatening consequences of these products and educating the patient and the caregivers of these risks. The case also emphasizes the need for serial liver enzymes monitoring for patients receiving these therapies as well as extensive research focusing on safety profile of these products in terms of different organ system affection other than their psychoactive potential.

Prevalence and Risk Factors of Neurologic Manifestations in Hospitalized Children Diagnosed with Acute SARS-CoV-2 or MIS-C.

BACKGROUND: Our objective was to characterize the frequency, early impact, and risk factors for neurological manifestations in hospitalized children with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or multisystem inflammatory syndrome in children (MIS-C). METHODS: Multicenter, cross-sectional study of neurological manifestations in children aged <18 years hospitalized with positive SARS-CoV-2 test or clinical diagnosis of a SARS-CoV-2-related condition between January 2020 and April 2021. Multivariable logistic regression to identify risk factors for neurological manifestations was performed. RESULTS: Of 1493 children, 1278 (86%) were diagnosed with acute SARS-CoV-2 and 215 (14%) with MIS-C. Overall, 44% of the cohort (40% acute SARS-CoV-2 and 66% MIS-C) had at least one neurological manifestation. The most common neurological findings in children with acute SARS-CoV-2 and MIS-C diagnosis were headache (16% and 47%) and acute encephalopathy (15% and 22%), both P < 0.05. Children with neurological manifestations were more likely to require intensive care unit (ICU) care (51% vs 22%), P < 0.001. In multivariable logistic regression, children with neurological manifestations were older (odds ratio [OR] 1.1 and 95% confidence interval [CI] 1.07 to 1.13) and more likely to have MIS-C versus acute SARS-CoV-2 (OR 2.16, 95% CI 1.45 to 3.24), pre-existing neurological and metabolic conditions (OR 3.48, 95% CI 2.37 to 5.15; and OR 1.65, 95% CI 1.04 to 2.66, respectively), and pharyngeal (OR 1.74, 95% CI 1.16 to 2.64) or abdominal pain (OR 1.43, 95% CI 1.03 to 2.00); all P < 0.05. CONCLUSIONS: In this multicenter study, 44% of children hospitalized with SARS-CoV-2-related conditions experienced neurological manifestations, which were associated with ICU admission and pre-existing neurological condition. Posthospital assessment for, and support of, functional impairment and neuroprotective strategies are vitally needed.