Pediatric Case Management

1
Pediatric Case Management

• The Childrens Hospital at Sinai
• October 25, 2005

2
October Cases-Ward

• 6 month old female with h/o NEC, admitted with
  bilious emesis (morbidity)
• 5 yo male with scrotal pain (morbidity)

3
October Cases-ER

• 17 year old with Sinusitis transferrred out for
  pneumocephalus

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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)

5
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 Hirshprungs Disease (morbidity)

6
Case Management 5yr old with left scrotal pain

• Kennon Harris, MD
• October 25, 2005

7
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

8
History, contd.

• 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

9
Emergency Department

• T37.3 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

10
Emergency Department

• NPO
• NS bolus (20 cc/kg), then IVF _at_ M
• Emesis X 1
• Labs
• Urine dip 1.015/7.5/neg
• WBC 18.5K (70.6 N 13.6 L 5.7 E)
• H/H12.9/36.1 Plts 286
• CMP WNL

11
Testicular Ultrasound
Left Testis
Right Testis
12
ER Management, contd.

• Urology consult
• Dx Testicular torsion vs. Hematoma
• Taken to OR for b/l scrotal exploration

13
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 60-70s, atropine given, HRgt 95
• Admitted to PICU postoperatively for close
  monitoring

14
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

15
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

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Hospital Course, contd.

• 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

17
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.

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Age Related Differences in the Presentation of
Appendicitis

• Neonates (birth 30 days)
• Infancy
• Preschool
• School-aged
• Adolescent

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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 (361, 39-50).
20
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

21
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.
22
References

• Pollack ES. Pediatric Abdominal Surgical
  Emergencies. Pediatric Annals 256, August
  1996 448-457.
• Rothrock, SG, Pagane, J. Acute Appendicitis in
  Children Emergency Department Diagnosis and
  Management. Annals of Emergency Medicine July
  2000 3950.
• Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of
  Acute Appendicitis Common Features After
  Litigation. The American Journal of Emergency
  Medicine July 1994 397-402

23
Topics for Discussion

• Work up for child with periumbilical tenderness
  and testicular pain
• Relationship between intra-abdominal findings and
  testicular compartment

24
Case Management Conference

• Brenda Figueroa, MD
• October 25th, 2005

25
TG 2 y/o girl with abdominal pain and vomiting

• HPI
• Sent to Sinais 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

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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

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ER Physical Exam

• VS 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 lt 2sec
• Lungs CTA b/l
• Abd normoactive BS,generalized tenderness, soft,
  guarding, ?RT, masses or HSM

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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

141
102
10
13.1
N 83 L 13.9 M 2.9
11.7
135
37.1
4.6
20
0.3
10.7
UA 3 ket, (-) leuk est/nit/blood/glu
29
Imaging Studies
Single dilated loop of bowel and air fluid level,
no specific evidence of obstruction
No infiltrates or effusions
30
Hospital Course B3

• VS 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, ?masses
• Plan Rehydration schedule for 5, Cont
  Ceftriaxone,NPO
• HD1 HR 88-124 RR 20-24 BP 121-129/67-72 Pain
  0-4
• Resp ? distress, CTA, ? O2 requirement. Lateral
  CXR obtained showing no evidence of pneumonia
• GI nl exam, emesis X 3 sm amount, NBNB,
  advanced to CLD did not tolerate

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Hospital Course, continued

• HD 2 HR 96-138 RR 22-32 BP 78-125/44-74 Pain 0-4
• GI emesis X 4 sm NBNB, Abd sl distended, soft,
  ()BS, not tolerating PO
• HD3 T 35.8 HR 125 RR 28 BP 107/81 Pain 0-4
• GI emesis x 6 bilious c/o abdominal pain
  squirms and points to R side Abd distended,
  soft, ? masses,?BS
• AXR/AUS performed, NGT placed

32
Images
Moderate dilatation of small bowel loops, with
fluid levels c/w small bowel obstruction
33
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
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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
• HD4 To B3
• Tolerated PO, BM
• DC home HD5

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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

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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 gt common in children gt5yrs

37
Viral Etiology of Intussusception

Rotavirus infection
Pediatr Infect Dis J, Vol 17(10).Oct 1998.893-898
CHANG Pediatr Infect Dis J, Vol 22 (2)
Feb2002.97-102
38
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
• lt15 pt with triad
• 20 no obvious pain
• 1/3 do not pass blood or mucus
• Pain alone

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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 lt1 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

Associated with spasm
Sensitivity 97 Specifity 87-91
Journal of Pediatric Gastroenterology
Nutrition. 39(5)511-518, November 2004
40
Diagnosis Treatment

• High index of suspicion
• AXR
• US
• CT scan
• Contrast studies

• Barium enema reduction
• Air contrast
• Surgery

41
References

• Seiji K, MD Mohamad M.,MD Intussusception in
  children Uptodate april 2005
• Bines JE, Ivanoff B, Justice F, Mulholland K,
  Clinical case definition for the diagnosis of
  acute intussusception Journal of Pediatric
  Gastroenterology and Nutrition Nov 2004 395
  511-518
• Hong-Yuan, H., Mdet al. Viral etiology of
  intussusception in taiwanese childhood Pediatric
  Infectious Disease Journal Oct. 1998 1710
  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 2310 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 153
  293-298
• Blakelock RT, Beasley SW, The clinical
  implications of non-idiopathic intussusception
  Pediatr Surg Int. Dec 1998 143 163-167
• 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

42
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