Pediatric emergency medicine trisk 2731 2731
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responds best to agents with efficacy against neuropathic pain such as gabapentin.
Such drugs rarely have immediate effect and thus narcotics may be needed in the
short run.
There is a wide differential to consider when evaluating a pediatric cancer patient
with new-onset cranial nerve palsy. Symmetric involvement may reflect vincristineinduced neuropathy, particularly when it involves ptosis. Increased ICP from shunt
malfunction or tumor progression should also be considered. Asymmetric
involvement can occur with fatigue or vincristine-induced exacerbation of baseline
weakness. Vincristine can also cause asymmetric ptosis in some patients, but this
should be a diagnosis of exclusion. Increased ICP should be suspected in a child
with a sixth nerve palsy. Carcinomatous meningitis should be considered in patients
with a history of tumors likely to involve the cerebrospinal fluid or meninges, such
as leukemia, lymphoma, parameningeal sarcomas, and meningeal seeding brain
tumors, such as medulloblastoma. Patients treated with a scopolamine patch for
nausea may develop pupillary asymmetry as scopolamine transferred by fingertip
from the patch to the eye can elicit unilateral mydriasis.
Management in the ED requires an appropriate oncology-directed history and
physical examination to establish the potential differential. Unless drug effect can be
established as the most likely cause, a head CT scan to rule out increased ICP may
be required. The CT scan findings may also direct the specific ED and post-ED
management. Admission for observation may be required for some patients where
the diagnosis or trajectory is uncertain.
The most common cause of proximal muscle weakness in pediatric cancer patients
is prolonged steroid exposure as part of cancer treatment or management of side
effects. The diagnosis can usually be established by the appropriate history and
physical examination. Patients with very severe symptoms whose families cannot
manage care at home may require admission for respite care or initiation of
rehabilitation.
Altered mental status in pediatric cancer patients has an extremely broad
differential ( Table 98.9 ). Cerebrovascular accident (CVA) as a cause of altered
mental status should be considered in patients with risk factors such as
thrombocytopenia, DIC, or drug-induced coagulopathy. Somnolence can be a side
effect of many supportive-care medications such as narcotics, gabapentin,
antihistamines, some antiepileptics, and antidepressants. Cranial radiation causes
somnolence syndrome 6 to 12 weeks after treatment that may last several weeks in
duration. Typical manifestations are extreme amounts of sleep (up to 20 hours per
day) with normal mental status and function when awake. Additional drug-specific
CNS side effects are listed in Table 98.8 .
