Pediatric Case Management
The Children’s Hospital at Sinai
October 25, 2005
October Cases-Ward 6 month old female with h/o NEC, admitted
with bilious emesis (morbidity) 5 yo male with scrotal pain (morbidity)
October Cases-ER 17 year old with Sinusitis transferrred out
for pneumocephalus
October Cases-PICU 17 yo female with CML (mortality) 4 month old with hepatoblastoma found to
have a femur fracture during hospitalization (morbidity)
15 yo female unresponsive (morbidity)
October Cases-NICU Ex 25 5/7 premature infant with IUGR and
respiratory failure (mortality) Ex 29 week premature infant transferred
from outside hospital with acute abdominal perforation and NEC (mortality)
FT infant re-admitted with bilious emesis found to have Hirshprung’s Disease (morbidity)
Case Management 5yr old with left scrotal pain
Kennon Harris, MDOctober 25, 2005
CC: R testicular swelling 5yo male presented to ED w/ 3 day hx of R
testicular pain/swelling hit by brother in groin area approx 13 days pta pain beginning 3 days later developed nausea, vomiting; mild diarrhea; no
fever Decreased appetite Noted to be “hunkered over” when walking
History, cont’d. PMH: s/p L blephoraplasty Imm: UTD; received Hep A 10 days pta Meds: none All: none Soc Hx: recently started Kindergarten Fam Hx: lives w/ parents and 6 siblings
Emergency DepartmentT37.3 HR92 RR18 BP101/66 O2 sat98% RA wt20.6 kg Gen: Anxious, NAD Pain score: 4 Abd: +periumbilical tenderness, no rebound, no
guarding; no rectal performed; nml bs; no hsm
GU: cirumcised male; R testicle higher than L; L testes larger than R; no tenderness, no erythema; no scrotal swelling; strong cremasteric reflexes b/l
Ext: NT, nml ROM Neuro: no deficits
Emergency Department NPO NS bolus (20 cc/kg), then IVF @ M Emesis X 1Labs: Urine dip: 1.015/7.5/neg; WBC 18.5K (70.6 N 13.6 L 5.7 E) H/H=12.9/36.1; Plts 286 CMP WNL
Right Testis
Left TestisTesticular Ultrasound
ER Management, cont’d.Urology consult: Dx: Testicular torsion vs. Hematoma
Taken to OR for b/l scrotal exploration
Hospital Course Intraop Findings: L testical abnormal in
appearance, but pink w/ bleeding parts; thickened but with no gross pathology, no hernia.
Biopsy taken Surgical consult PACU: HR 60-70’s, atropine given, HR> 95 Admitted to PICU postoperatively for close
monitoring
CT abd/pelvis w/ contrast: R lower quadrant abscess w/ associated L
scrotal abscess (may represent sequelae of ruptured appendicitis, as appendix not well visualized)
Prominence of small bowel loops which may represent evolving ileus or sbo
B/L lower lobe infiltrates
Hospital Course Admitted to PICU monitoring/observation
Operative Diagnosis: Ruptured Appendix with abscess
Admitted to PICU postoperatively
Treated with Clindamycin, Zosyn Wound Cx: Ecoli, strep viridans, provetella,
bacteroides
Hospital Course, cont’d. Testicular Biopsy: benign fibrovascular tissue
containing small amounts of skeletal muscle w/ mild acute and chronic inflammation
Appendix Biopsy: suppurative appendicitits and periappendicitis w/perforation and florid fibrinopurulent exudate formation
Repeat testicular U/S on HD # 4: hypoechoic L testicle surrounded by a hypervascular periphery
Challenges In Correct Diagnosis of Appendicitis Misdiagnosis rates range from 28-57% for
children 12 years or older Nearly 100% for those 2 years or younger Among the five leading causes of litigation
against emergency room physicians Appendiceal perforation is nearly universal
in children 3 yrs or younger.
Age Related Differences in the Presentation of Appendicitis Neonates (birth – 30 days) Infancy Preschool School-aged Adolescent
Initial misdiagnosis in childhood appendicitis Gastroenteritis 42% Upper Respiratory Tract infection 18% Pneumonia 4% Sepsis 4% UTI 4% Encephalitis/Encephalopathy 2% Febrile Seizure 2% Blunt Abdominal Trauma 2% Unknown 22%
S. Rothrick, and J. Pagane. Acute Appendicitis in Children: Emergency Department Diagnosis and Management. Annals of Emergency Medicine. July 2000 (36:1, 39-50).
Challenges In Correct Diagnosis of Appendicitis Laboratory Adjuncts
WBC Count CRP
Radiologic Evaluation Plain radiographs Radioisotope-labeled WBC scanning Ultrasound CT*-Gold Standard
Scoring Systems MANTRELS score in children-not accurate
Challenges In Correct Diagnosis of Appendicitis Patient most likely to have missed diagnosis
of appendicitis on initial ED visit: No “classic” signs Pain, but no nausea/vomiting No rectal exam performed Administration of a narcotic pain medication Diagnosis of gastroenteritis No follow-up examination within 12-24 hrs.
R.A. Rusnack, J.M. Borer, J.S. Fastow. Misdiagnosis of Acute Appendicitis: Common Features Discovered in Cases after Litigation. American Journal of Emergency Medicine. July 1994 12 (4): 397-402.
References• Pollack ES. Pediatric Abdominal Surgical
Emergencies. Pediatric Annals; 25:6, August 1996: 448-457.
• Rothrock, SG, Pagane, J. Acute Appendicitis in Children: Emergency Department Diagnosis and Management. Annals of Emergency Medicine; July 2000: 39=50.
• Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of Acute Appendicitis: Common Features After Litigation. The American Journal of Emergency Medicine; July 1994: 397-402
Topics for Discussion Work up for child with periumbilical
tenderness and testicular pain Relationship between intra-abdominal
findings and testicular compartment
Case Management Conference
Brenda Figueroa, MDOctober 25th, 2005
TG 2 y/o girl with abdominal pain and vomiting HPI:
Sent to Sinai’s Peds ER by PMD 1 day abdominal pain,R sided, intermittent, intense,
lasting 1 min every 5 min No aggravating or relieving factors Vomiting “too many times to count” NB,NB, preceded
by pain ↑ sleepiness, nl appetite, ∅ fever or cough Last BM 1d PTA nl
History PMHx:
Ex- 32wks born C/S in NY prenatal labs neg; NICU stay 1 mo for
prematutity “bladder infection” 2mo
ago Immunizations: UTD Allergies: NKDA Family Hx: non-
contributury
Soc. HX: Lives with parents ,
sister, aunt & uncle
Personal Hx: Development age
appropiate
ER Physical ExamVS: T 35.1 HR 130 RR20 PO2 99% RA
BP 131/67 Pain scale 4/10 Gen App: sleepy but arousable HEENT: ∅nasal dc,nl pharynx, TMI,∅LAD CVS: nl S1S2 ∅ murmurs, Cap refill < 2sec Lungs: CTA b/l Abd: normoactive BS,generalized tenderness,
soft, + guarding, ∅RT, masses or HSM
Management NS bolus 20cc/kg X 2, then M Zofran 2 mg IV X 1 CXR & AXR Labs:
Ceftriaxone 1 G IV X 1
Admitted to B3 Peds
11.713.1
37.1135
141
4.6
102
20
10
0.310.7
N 83 L 13.9 M 2.9
UA: 3+ ket, (-) leuk est/nit/blood/glu
Imaging Studies
Single dilated loop of bowel and air fluid level, no specific evidence of obstruction
No infiltrates or effusions
Hospital Course B3VS T 36.5 HR 103 RR 20 BP 121/72 POx 98% Exam: Sleepy but arousable, Lungs CTA, Abd exam soft,
NT, ND, nl BS, ∅massesPlan: Rehydration schedule for 5%, Con’t Ceftriaxone,NPO
HD#1: HR 88-124 RR 20-24 BP 121-129/67-72 Pain 0-4Resp: ∅ distress, CTA, ∅ O2 requirement. Lateral CXR
obtained showing no evidence of pneumoniaGI: nl exam, emesis X 3 sm amount, NBNB, advanced
to CLD did not tolerate
Hospital Course, continued HD #2 HR 96-138 RR 22-32 BP 78-125/44-74
Pain 0-4GI: emesis X 4 sm NBNB, Abd sl distended, soft, (+)BS, not
tolerating PO
HD#3 T 35.8 HR 125 RR 28 BP 107/81 Pain 0-4GI: emesis x 6 bilious c/o abdominal pain “squirms and
points to R side” Abd: distended, soft, ∅ masses,↓BSAXR/AUS performed, NGT placed
Images
Moderate dilatation of small bowel loops,with fluid levels c/w small bowel obstruction
Ultrasound
Dilatation of bowel loops with fluid. Reniform soft tissue mass in R mid abdomen with an echogenic center and echopenic margins c/w Intussusception
OR Findings & subsequent progress Reduction was attempted with barium enema Exploratory laparotomy
Reduction of ileo-ileocolonic intussusception Bowel viable
Observed in PICU ∅ emesis, NGT dc
HD#4 To B3 Tolerated PO, + BM
DC home HD#5
Intussusception in Children One of the most common causes of acute intestinal
obstruction A segment of bowel invaginates into the distal
bowel Results in venous congestion & bowel wall edema Obstruction of arterial blood supply, bowel
infarction, perforation, death
Incidence & Etiology 0.3-2.5 cases per 1000 live births mortality uncommon case fatality rates up to 50% in developing
countries idiopathic cause most cases
↑ seasons of viral gastroenteritis Associated with rotavirus vaccine
lead point > common in children >5yrs
Viral Etiology of Intussusception
Pediatr Infect Dis J, Vol 17(10).Oct 1998.893-898 CHANG: Pediatr Infect Dis J, Vol 22 (2) Feb2002.97-102
Rotavirus infection
Clinical Manifestations & Physical Findings intermittent, severe,
crampy abdominal pain Vomiting, initially NB,
becomes bilious with progression
Between episodes child behaves normally
As it progress lethargy appears
“currant jelly” stools Sausage shaped
abdominal mass <15% pt with triad 20% no obvious pain 1/3 do not pass blood
or mucus Pain alone
Clinical Case definition for the diagnosis of acute intussusception Major Criteria
Evidence of intestinal obstruction
Features of intestinal invagination (1 or more)
Evidence of intestinal vascular compromise
Minor Criteria Age <1 yr & male Abdominal pain Vomiting Lethargy Pallor Hypovolemic shock Abnormal but non-specific bowel
pattern of x-ray Definite-surgical/radiological
criteria Probable-2 major, or 1 major 3
minor Possible- 4 or more minor
Journal of Pediatric Gastroenterology & Nutrition. 39(5):511-518, November 2004
Associated with spasm
Sensitivity 97% Specifity 87-91%
Diagnosis & Treatment High index of
suspicion AXR US CT scan Contrast studies
Barium enema reduction
Air contrast Surgery
ReferencesSeiji K, MD Mohamad M.,MD Intussusception in children Uptodate april 2005Bines JE, Ivanoff B, Justice F, Mulholland K, Clinical case definition for the diagnosis of
acute intussusception Journal of Pediatric Gastroenterology and Nutrition Nov 2004 39:5 511-518
Hong-Yuan, H., Mdet al. Viral etiology of intussusception in taiwanese childhood Pediatric Infectious Disease Journal Oct. 1998 17:10 893-898
Velazquez, F.R, MD et al Natural rotavirus infection is not associated to intussusception in Mexican children Pediatric Infectious Disease Journal October 2004 23:10 S173-S178
Yamamoto LG, Morita, SY, Boychuck, RB,Inaba IS, Rosen LM, Yee LL, Young LL, Stool appearance in intussusception: assessing the value of the term “currant jelly” Am J Emerg Med. May 1997 15:3 293-298
Blakelock RT, Beasley SW, The clinical implications of non-idiopathic intussusception Pediatr Surg Int. Dec 1998 14:3 163-167
Chang EJ, MD et al, Lack of assosociation between rotavirus infection and intussusception: implication for us eof attenuated rotavirus vaccines Pediatr Infect Dis J, Vol 22 (2) Feb2002.97-102
Points for Discussion: Initial interpretation of imaging vs. final
reading Documentation of multiple discussions re: film
No physical exam findings c/w pneumonia Importance of index of suspicion in child
with intermittent abdominal pain and vomiting
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