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