Children With Minor Head Injury

Pediatric Minor Head Injury: PECARN-Guided CT and Observation

Scope

• This note reorganizes the provided clinical summary on children with minor blunt head trauma.
• It applies to children with Glasgow Coma Scale (GCS) 14 to 15.
• It does not apply to suspected abusive head trauma.

Core Approach

• Use Pediatric Emergency Care Applied Research Network (PECARN) criteria to risk-stratify children and guide the decision between observation and head computed tomography (CT).
• The primary goal is to identify clinically important traumatic brain injury (ciTBI) while avoiding unnecessary radiation exposure.
• There are 3 practical risk groups:
  • Very low risk: no PECARN risk factors. CT is not recommended; observation alone is appropriate.
  • Intermediate risk: observation versus CT is selected according to the clinical context.
  • High risk: CT is generally indicated.

Intermediate-Risk Features

• For children 2 years or older:
  • History of loss of consciousness.
  • Vomiting.
  • Severe mechanism of injury.
  • Severe headache.
• Do not use this note as a substitute for the original age-specific PECARN algorithm.

When CT Should Be Favored Over Observation

• Parental preference after informed discussion.
• Multiple risk factors.
• Worsening symptoms during observation.
• Young infants, when serial observation is more difficult to assess.
• High-risk features:
  • GCS 14.
  • Altered mental status, including agitation, somnolence, repetitive questioning, or slow response.
  • Signs of skull fracture.
• Posttraumatic seizure is not a formal PECARN variable, but the source advises a lower threshold for CT.

Observation Strategy

• Observation before CT decision-making may reduce imaging without increasing missed ciTBI in appropriately selected children.
• The supplied summary reports:
  • A PECARN secondary analysis found lower CT use with observation: adjusted odds ratio (OR) 0.53, without an increase in missed ciTBI.
  • A multicenter study of more than 18,000 children found planned observation was associated with lower CT use overall: adjusted OR 0.2.
  • The same summary reports the greatest reduction in intermediate-risk and high-risk groups, with no difference in missed injuries.
  • Each additional hour of emergency department observation was associated with a lower CT rate after adjustment for time since injury.
  • Roughly 4 to 6 hours of monitored observation was described as substantially reducing CT use without missed important injuries or prolonged emergency department stays.
• During observation:
  • Perform serial neurologic assessments.
  • Document symptom progression or resolution.
  • Escalate to CT if symptoms persist, worsen, or new abnormal neurologic findings emerge.

Disposition

• Safe discharge after observation requires a reliable caregiver who can recognize deterioration and return promptly.
• Provide clear return precautions for worsening headache, repeated vomiting, altered behavior, seizure, inability to awaken normally, new weakness, gait disturbance, or other neurologic deterioration.

Key Takeaway

In children with minor blunt head trauma, PECARN-guided risk stratification can support selective CT use. For carefully selected intermediate-risk patients, structured emergency department observation with serial reassessment may safely reduce CT utilization.

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Confirm age-specific criteria and apply current local protocols before patient-level decisions.

Antibody-Drug Conjugate Toxicity

Antibody-Drug Conjugate Toxicity: Emergency Medicine Lecture Notes

Source

• Markides DM, Hita AG, Merlin J, Reyes-Gibby C, Yeung SJ. Antibody-Drug Conjugates: The Toxicities and Adverse Effects That Emergency Physicians Must Know. Annals of Emergency Medicine. 2025;85(3):214-229. doi:10.1016/j.annemergmed.2024.10.015

Why Emergency Clinicians Need to Recognize ADC Toxicity

• Antibody-drug conjugates (ADCs) combine a monoclonal antibody, linker, and cytotoxic payload to deliver treatment preferentially to tumor cells.
• Toxicity still occurs through target-related effects, payload leakage or off-target exposure, and incompletely understood mechanisms.
• Common adverse effects include myelosuppression, nausea and vomiting, diarrhea, peripheral neuropathy, and rash.
• Emergency care adds the greatest value by recognizing serious toxicities that mimic common presentations or become life-threatening when diagnosis is delayed.
• Real-world emergency department presentation rates for ADC-related adverse effects remain uncertain.

First Emergency Department Step

• Obtain 2 medication-history details immediately:
  • Exact ADC name.
  • Date and time of the most recent dose.
• Contact the treating oncology team for every suspected ADC-related toxicity because dose delay, reduction, or discontinuation may be required.

Life-Threatening Toxicities

Interstitial Lung Disease and Pneumonitis

• Consider in patients receiving trastuzumab deruxtecan (T-DXd), mirvetuximab soravtansine, brentuximab vedotin, enfortumab vedotin, trastuzumab emtansine (T-DM1), or tisotumab vedotin.
• Presentations are nonspecific: dry cough, exertional dyspnea, fatigue, chest pain, fever, wheezing, or crackles.
• Chest radiography has limited sensitivity. If ADC-related interstitial lung disease is in the differential diagnosis, obtain high-resolution chest computed tomography (CT).
• CT may show diffuse patchy consolidation, interlobular reticular opacities, and septal thickening.
• Treat infection and inflammation in parallel:
  • Empiric antibiotics may be appropriate because infectious and drug-related pneumonitis are difficult to distinguish initially.
  • Do not delay corticosteroids solely while awaiting microbiologic results when drug pneumonitis is suspected.
  • Grade 2: oral prednisone equivalent 1 to 2 mg/kg/day may be used, with disposition guided by clinical status.
  • Grade 3: oxygen, hospital admission, and prednisolone 1 mg/kg/day.
  • Grade 4: manage as respiratory failure; methylprednisolone 2 mg/kg/day or pulse methylprednisolone 500 to 1,000 mg/day for 3 days is described.
  • If no improvement after 48 to 72 hours, reported escalation options include infliximab, tocilizumab, mycophenolate mofetil, or intravenous immunoglobulin.
• Obtain early pulmonary consultation. Bronchoscopy with bronchoalveolar lavage is often needed.

Sinusoidal Obstruction Syndrome

• Most associated with gemtuzumab ozogamicin and inotuzumab ozogamicin.
• Early clue: rapid weight gain.
• Later findings: edema, ascites, jaundice, tender hepatomegaly, pleural effusions, hypoxemia, encephalopathy, and renal failure.
• Evaluate bilirubin, aminotransferases, platelet count, renal function, and abdominal ultrasonography with hepatic venous flow assessment.
• Begin supportive management without waiting for definitive confirmation:
  • Correct fluid and electrolyte abnormalities.
  • Use cautious diuresis for volume overload, such as furosemide or spironolactone when appropriate.
  • For respiratory compromise from ascites, therapeutic drainage may be considered; the source recommends limiting a single drainage to 1 L to protect renal function.
  • Consider renal replacement therapy or ultrafiltration when fluid cannot be controlled.
• Defibrotide is the evidence-supported specific therapy described in the source: 6.25 mg/kg every 6 hours for 21 days. Initiate urgently for severe disease and consider it for persistent mild to moderate disease despite 2 days of supportive care.

Hyperglycemia and Diabetic Ketoacidosis

• Enfortumab vedotin is associated with severe hyperglycemia and reported diabetic ketoacidosis, including in patients without known diabetes.
• Polatuzumab vedotin and brentuximab vedotin have also been associated with hyperglycemia and ketoacidosis.
• For thirst, polyuria, weakness, nausea, or altered mental status, use a low threshold to measure serum glucose and ketones.
• Treat diabetic ketoacidosis using standard emergency protocols.

Tumor Lysis Syndrome

• Consider with gemtuzumab ozogamicin, polatuzumab vedotin, and brentuximab vedotin.
• Evaluate patients at risk with electrolytes, renal function, calcium, phosphate, uric acid, and electrocardiography as clinically indicated.
• Manage according to standard tumor lysis syndrome pathways and involve oncology early.

Hemorrhage

• Tisotumab vedotin and T-DM1 can cause clinically significant bleeding.
• Gemtuzumab ozogamicin and inotuzumab ozogamicin may cause bleeding through thrombocytopenia.
• Assess platelet count, coagulation studies when indicated, bleeding site, hemodynamic status, and intracranial symptoms.
• Maintain heightened concern for intracranial bleeding or hematoma expansion in patients with brain metastases, especially after radiation therapy.

Infusion-Related Reactions

• Reactions commonly occur 30 to 120 minutes after infusion but severe or delayed reactions may present more than 24 hours later.
• Features include fever, generalized maculopapular rash, chills, nausea, and pruritus.
• Clinical distinction from an allergic reaction may not be possible in the emergency setting.
• Treat as anaphylaxis or severe hypersensitivity when clinically indicated and coordinate with oncology.

Other High-Yield Presentations

Ocular Toxicity

• Mirvetuximab soravtansine may cause blurred vision, dry eye, and keratopathy.
• Tisotumab vedotin may cause conjunctivitis and keratitis.
• Keratitis warrants topical treatment and ophthalmology referral.
• Suspected uveitis requires urgent ophthalmology evaluation and may require local or systemic corticosteroids.
• Notify oncology because treatment interruption or dose modification may be required.

Liver Test Abnormalities

• Aminotransferase elevation greater than 20 times the upper limit of normal, or any elevation with jaundice, warrants expedited evaluation and oncology plus hepatology consultation.
• Asymptomatic elevation 5 to 15 times the upper limit of normal without jaundice may be suitable for close outpatient reassessment within days, depending on the full clinical context and oncology guidance.

Progressive Multifocal Leukoencephalopathy

• Associated with brentuximab vedotin and polatuzumab vedotin.
• Although rare, it may be fatal.
• Consider with progressive language, motor, cognitive, visual, or gait dysfunction over weeks to months.
• Magnetic resonance imaging is preferred over CT. Cerebrospinal fluid JC virus polymerase chain reaction can support the diagnosis.

Effusions and Peripheral Edema

• Loncastuximab tesirine may cause peripheral edema, pleural effusion, and pericardial effusion.
• In a dyspneic patient receiving this ADC, evaluate for effusions in addition to pneumonia or pulmonary embolism.

Gastrointestinal Toxicity and Pancreatitis

• Diarrhea and vomiting may require aggressive intravenous fluid and electrolyte replacement, not only antiemetics.
• Grade 1 diarrhea: oral hydration and loperamide.
• Grade 2 diarrhea: intravenous fluids and consideration of octreotide.
• Grade 3 or higher diarrhea: hospital admission and electrolyte correction.
• Brentuximab vedotin is associated with pancreatitis, including reported fatal cases. Evaluate and manage as standard acute pancreatitis; fasting triglycerides may be useful.

Severe Cutaneous Reactions

• Enfortumab vedotin, tisotumab vedotin, and brentuximab vedotin have reported Stevens-Johnson syndrome and toxic epidermal necrolysis.
• Treat suspected severe cutaneous adverse reactions according to standard emergency and specialty pathways.

Cardiac Toxicity

• Cardiac toxicity is uncommon but includes reduced left ventricular ejection fraction and QTc prolongation with T-DXd, as well as cardiac events with T-DM1.
• Evaluate and treat using standard acute cardiovascular pathways because no ADC-specific emergency treatment is established.

Practical Emergency Department Checklist

• Identify the exact ADC and last administration date.
• For respiratory symptoms with T-DXd or mirvetuximab, consider pneumonitis and obtain CT rather than relying on chest radiography alone.
• For dyspnea with loncastuximab tesirine, actively assess for pleural or pericardial effusion.
• For rapid weight gain, ascites, jaundice, or hepatic pain with gemtuzumab ozogamicin or inotuzumab ozogamicin, consider sinusoidal obstruction syndrome.
• For thirst or polyuria with enfortumab vedotin, measure glucose and ketones promptly.
• Maintain a low threshold to admit, consult the relevant specialty service, and contact the treating oncology team.

Key Takeaway

In patients receiving ADCs, medication identification and timing of the last dose reshape the differential diagnosis. Early recognition of pneumonitis, sinusoidal obstruction syndrome, hyperglycemia or diabetic ketoacidosis, tumor lysis syndrome, hemorrhage, and delayed infusion reactions may prevent avoidable harm.

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Generated from the provided source note. Clinical decisions should be made in consultation with oncology and relevant specialty services.

Adrenal Crisis

Adrenal Crisis: Recognize, Treat, Prevent

Definition

• Adrenal crisis is a life-threatening deterioration caused by inadequate cortisol during physiologic stress.
• Treat suspected crisis immediately. Do not delay emergency treatment for confirmatory testing.

When to Suspect Adrenal Crisis

• Consider adrenal crisis in a patient with known or possible adrenal insufficiency who has:
  • Severe weakness
  • Abdominal pain
  • Persistent vomiting
  • Hypotension
  • Confusion
  • Loss of consciousness
• Common listed triggers include:
  • Infection
  • Injury or trauma
  • Surgery
  • Acute illness
  • Abrupt cessation of chronic glucocorticoids

Primary Versus Secondary Adrenal Insufficiency

Primary Adrenal Insufficiency

• Adrenal destruction causes low cortisol and low aldosterone.
• ACTH is elevated.
• Salt craving and hyperpigmentation support this pattern.
• Low sodium plus high potassium supports primary adrenal insufficiency.

Secondary Adrenal Insufficiency

• Pituitary ACTH deficiency lowers cortisol.
• Aldosterone is generally preserved.
• Chronic glucocorticoid exposure and withdrawal are important causes.
• Low sodium plus high potassium should not be used to support secondary adrenal insufficiency because this pattern favors primary disease.

Immediate Emergency Treatment

• Do not wait for confirmatory testing when crisis is suspected.
• Give hydrocortisone 100 mg intravenously or intramuscularly immediately.
• Continue hydrocortisone at 50 mg every six hours.
• Resuscitate with intravenous normal saline.
• Identify and treat the precipitating illness, including infection when present.
• Transfer or escalate urgently to emergency care.

Diagnostic Clarification After Stabilization

• Once stabilization is underway, use the following to clarify the diagnosis:
  • Focused history and physical examination
  • Morning cortisol
  • ACTH
  • Serum electrolytes
  • Cosyntropin stimulation testing
• A low cortisol response to cosyntropin supports adrenal insufficiency.
• ACTH helps distinguish primary from secondary disease.
• Determine the underlying cause with targeted autoimmune testing or imaging.

Prevention and Sick-Day Planning

• Prevention is part of ongoing clinical care.
• Patients receiving replacement therapy need:
  • Consistent medication use
  • Medical identification alert
  • Emergency steroid card
  • A written plan for illness or surgery
• The local teaching summary advises:
  • Mild illness: double the usual dose.
  • Moderate illness: increase to two or three times the usual dose.
  • Severe illness, trauma, or surgery: use parenteral hydrocortisone.

Clinical Pitfalls

• Never advise abrupt cessation of glucocorticoids.
• Primary and secondary adrenal insufficiency are not interchangeable.
• Do not delay emergency treatment while waiting for diagnostic confirmation.
• Follow local protocols and specialist guidance for dosing, tapering, and disposition.

Summary Takeaway

• Suspect adrenal crisis when adrenal insufficiency is possible and severe stress-related symptoms or hemodynamic instability are present.
• Treat immediately with hydrocortisone, intravenous normal saline, and management of the precipitating illness.
• Use ACTH, electrolytes, cortisol testing, and cosyntropin testing after stabilization to clarify the diagnosis.
• Prevent recurrence with adherence, identification, emergency steroid resources, and a clear sick-day plan.

Source boundary: This is a local teaching summary. Follow local protocols and specialist guidance for dosing, tapering, and disposition.