Scott Herskovitz, Inova Children’s Hospital
with Theresa Walls, Children’s National Medical Center

The Case
13yo M presented with headache and influenza symptoms, then developed agitation after receiving treatment for a migraine. This case focused on two things: workup for the acutely encephalopathic patient, and strategies for managing acute agitation in the pediatric ED.

Here’s How You Answered Our Questions

Of note, there seemed to be a bit of a disconnect between the voting results and the comments. Most commenters leaned towards a broad encephalopathy workup, while voters were more inclined to treat the patient’s symptoms and observe him.

Denouement:
After Haldol, the patient’s agitation resolved and he fell asleep. The total length of agitation was about 90 minutes. He was admitted to the ICU step-down unit for observation.

The patient slept through the night without any further agitation and remained hemodynamically stable. The next morning, the patient awoke at his baseline mental status without any headache, neck pain, or photophobia. He was tolerating regular diet without any further nausea or vomiting. No further workup was performed, and his symptoms in the ED were ultimately ascribed to a dystonic reaction from Reglan, which caused the patient significant anxiety and distress. He was discharged home.

Discussion:
Theresa Walls, our teaching attending for the week, posted an excellent comment outlining her thoughts and initial workup.

We were lucky enough to have Scott Herskovitz, the author of this case, available via teleconference during our discussion. He reinforced the low clinical suspicion that the ED team had for meningo-encephalitis, as the patient was afebrile and had a reassuring exam on presentation. Because the agitation occurred within 5 minutes of Reglan administration, the ED team felt that a medication reaction was overwhelmingly the most likely diagnosis. He added that while an acute dystonic reaction would be expected to resolve rapidly after administration of Benadryl, there are case reports of medication-induced dystonic reactions that respond more slowly to treatment. Another theory offered by the group was that the patient’s anxiety persisted even after the dystonic reaction had resolved, which caused the prolonged period of agitation.