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Hypothermia for Traumatic Brain Injury in Children Corticosteroids Don't From the publishers of The New England Journal of Medicine July 2008 Vol. 12 No. 7 Hypothermia for ated with an unfavorable outcome, the Hutchison JS et al. Hypothermia therapy odds ratio for an unfavorable outcome after traumatic brain injury in children. Traumatic Brain Injury with hypothermia therapy was 2.33. N Engl J Med 2008 Jun 5; 358:2447. in Children Death rates did not differ significantly nimal models and small studies in between the hypothermia and normo- A children and adults suggest a bene- thermia groups (21% vs. 12%). No evi- Corticosteroids Don’t fit for hypothermia therapy in the treat- dence of benefit was detected in analy- Reduce Mortality ment of severe traumatic brain injury. ses of any of eight subgroups, including patients who were treated early. in Children with In an international trial, researchers Bacterial Meningitis compared outcomes in children (age Comment: range, 1–17 years) with traumatic brain This study was remarkably ambitious, dministration of adjuvant cortico- injury who were randomized to either given the low incidence of eligible pa- A steroids mitigates hearing loss in hypothermia therapy for 24 hours tients (5 per month in 17 pediatric children with Haemophilus influenzae (32.0°C–33.0°C) or normothermia hospitals in 3 countries). Despite this type B (Hib) meningitis. However, the (36.5°C–37.5°C). Eligible patients had obstacle, the researchers showed un- introduction of vaccines against Hib in Glasgow Coma Scale scores 8 at the ≤ equivocally that hypothermia has no 1985 and against Streptococcus pneu- scene or in the emergency department, benefit. Although a greater proportion moniae in 2000 has greatly altered the needed mechanical ventilation, and had of children who were treated with hypo- landscape of bacterial meningitis in chil- evidence of acute brain injury on com- thermia than with normothermia had dren. In a retrospective cohort study, puted tomography scan. Patients who poor outcomes, the difference did not these authors reviewed data from 27 U.S. were screened more than 8 hours after reach statistical significance. Induced children’s hospitals to determine the injury or who had refractory shock, hypothermia is not indicated for treat- effect of adjuvant corticosteroid therapy nonaccidental injury, high cervical spinal ment of acute severe brain injury in on mortality and time to discharge in cord injury, or acute isolated epidural children. children younger than 18 years who were hematoma were excluded. — J. Stephen Bohan, MD, MS, discharged with a diagnosis of bacterial Of 1441 patients who were screened FACP, FACEP meningitis from 2001 through 2006. during more than 5 years, 327 met eli- gibility criteria and 225 were enrolled. Complete data were available for 91% TABLE OF CONTENTS of enrolled patients. Mean time from Hypothermia for Early Repolarization: injury to initiation of cooling was 6.3 Traumatic Brain Injury Maybe Not So Benign After All ......... 53 hours, and mean time to achieve hypo- in Children .........................................49 Femoral Vein Central Lines thermia was 3.9 hours. Significantly more Corticosteroids Don’t Reduce in Children: Another Case patients in the hypothermia group than Mortality in Children for Ultrasound Guidance ...................53 in the normothermia group received vaso- with Bacterial Meningitis .................. 49 Death After Syncope: active drugs for hypotension, usually Facilitated PCI Is Not Effective Can We Predict It? ............................. 53 during the rewarming period. for STEMI ........................................... 50 Noninvasive Ventilation Is Safe The proportion of patients with an Oral Prednisolone for Gout ....................51 and Effective in Acute Decompensated Heart Failure ........... 54 unfavorable outcome — defined as severe Oligoanalgesia in Women with Abdominal Pain ..........................51 Needle-Free Powder Lidocaine Delivery ...54 disability, death, or persistent vegetative Bivalirudin During PCI in Patients Risk Factors for Delay state at 6 months (the primary outcome) with Acute MI .....................................51 in Presentation of AMI Patients .........54 — was 31% in the hypothermia group Clinical Performance Minimal Risk for Shock to Rescuers and 22% in the normothermia group, a of the Airway Scope .......................... 52 During Biphasic Defibrillation ..........55 nonsignificant difference (relative risk C-Spine Movement: Macintosh vs. Patient Outcomes for an unfavorable outcome with hypo- Airtraq Laryngoscope ........................52 from Intensivist Care .........................55 thermia therapy, 1.41). After adjustment Management of Cocaine-Associated Don’t Delay Transfer of Trauma for clinical factors that might be associ- Chest Pain and MI ..............................52 Patients to Specialty Centers .............56 Journal Watch (and its design) is a registered trademark of the Massachusetts Medical Society. An editorially independent literature-surveillance newsletter summarizing articles from major medical journals. ©2008 Massachusetts Medical Society. All rights reserved. Disclosure information about our authors can be found at http://emergency-medicine.jwatch.org/misc/board_disclosures.dtl Page 50 JOURNAL WATCH EMERGENCY MEDICINE Volume 12 Number 7 Among 2780 children (median age, myocardial infarction (STEMI; excluding EDITOR-IN-CHIEF Ron M. Walls, MD, FRCPC, FACEP, FAAEM 9 months), 8.9% received adjuvant corti- localized inferior infarction) and who Chair, Department of Emergency Medicine, costeroid therapy. The leading bacterial presented within 6 hours of symptom Brigham and Women’s Hospital, Boston; pathogens were S. pneumoniae (18%) onset received one of three treatments: Professor of Medicine, Harvard Medical School and Neisseria meningitidis (10%). The (1) half-dose reteplase plus abciximab DEPUTY EDITOR overall mortality rate was 4.2%. Adjuvant started immediately after randomization John A. Marx, MD, FAAEM, FACEP Chair and Chief, Department of Emergency corticosteroid therapy did not reduce (combination-facilitated PCI), (2) abcix- Medicine, Carolinas Medical Center, Charlotte; mortality or time to discharge in any age imab alone started immediately after Adjunct Professor of Emergency Medicine, groups (<1 year, 1–5 years, or >5 years) randomization (abciximab-facilitated University of North Carolina, Chapel Hill or in subgroups of children with pneumo- PCI), or (3) abciximab started in the EXECUTIVE EDITOR coccal or meningococcal meningitis. catheterization lab (primary PCI). A Cara Adler, MS Massachusetts Medical Society Corticosteroid use increased signifi- larger enrollment had been planned, but ASSOCIATE EDITORS cantly from 5.8% in 2001 to 12.2% in 2006. the study was stopped early for a variety of reasons, including cost overruns and Aaron E. Bair, MD, MSc, FAAEM, FACEP Comment: Associate Professor, Department of Emergency concern in the U.S. that the random- Medicine, University of California, The putative beneficial effects of cortico- Davis Medical Center ization process interfered with the steroids are ascribed to reduction of 90-minute door-to-balloon goal. Jill M. Baren, MD, MBE, FACEP, FAAP the inflammatory response caused by Director, Pediatric Emergency Medicine Education, The combination-facilitated PCI Department of Emergency Medicine, antimicrobial-induced bacteriolysis. But group had significantly greater ST- Hospital of the University of Pennsylvania; corticosteroids also have adverse effects, segment resolution 60 to 90 minutes after Associate Professor of Emergency Medicine and including the possibility of decreasing Pediatrics, University of Pennsylvania School of initiation of treatment and significantly Medicine; Associate, University of Pennsylvania delivery of antibiotics into cerebrospinal lower creatine kinase (CK) levels (meas- Center for Bioethics, Philadelphia fluid. The findings of a Cochrane review ured during the first 24 hours after en- Diane M. Birnbaumer, MD, FACEP and a large clinical study both published rollment) than the other two groups. Associate Residency Director, Department of in 2007 are in line with those of this Emergency Medicine, Harbor-UCLA Medical Center, However, the incidence of the primary Torrance; Professor of Clinical Medicine, UCLA analysis. However, guidelines from the endpoint (a composite of all-cause J. Stephen Bohan, MD, MS, FACP, FACEP American Academy of Pediatrics state death, ventricular fibrillation occurring Executive Vice Chairman, Department of Emergency that “adjunctive therapy with dexameth- more than 48 hours after randomiza- Medicine, Brigham and Women’s Hospital, Boston; asone may be considered after weighing Assistant Professor, Harvard Medical School tion, cardiogenic shock, and congestive the potential benefits and risks.” Such Kristi L. Koenig, MD, FACEP heart failure within 90 days) was about Director of Public Health Preparedness; equivocal recommendations and the fail- 10% in all three groups. The incidence Professor of Clinical Emergency Medicine, ure of practitioners to appreciate the of major bleeding was significantly Department of Emergency Medicine, effect of vaccination have been partly University of California, Irvine higher in the combination-facilitated responsible for the increase in use of PCI group than in the primary PCI Tiffany M. Osborn, MD corticosteroids for children with menin- Assistant Professor, Department of Emergency group. The authors and an editorialist Medicine and Surgical/Trauma Critical Care, gitis. The findings
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