Pediatric Case Management The Children's Hospital at Sinai

  • 696 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
696
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
14
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • (no po on doa) Accompanied by an older sister in the ED
  • Attributed the diarrhea that developed the same day to having received Hep A shot.
  • R testes nml flow; L testes w/ focal area of decreased echogenicity;some bloodflow seen in soft tissue surrounding the left testis no blood flow within left testis; moderate-marked inhomogeneous thickening surrounding testis which is mildly vascular; small L hydrocele; L epididymal orchitis vs peritesticular organizing hematoma vs testicular torsion.
  • Taken to the OR for b/l scrotal exploration w/likely L orchiectomy w/ R ochidopexy
  • Intraop findings:Difficult to identify the L testes completely because of significant reactive tissue changes in the left hemiscrotum. The testis appeared swollen, edematous and the decision was made to biopsy it. Given that the patient did not have torsion, there was a great deal of concern as to what pathology had resulted in the patient’s pain and a abd CT was recommended. Surgical Consult: pain not classic for appendicitis, however given uncertainty surrounding the history, agree with CT abd to r/o appy. Scrotal abscess thought to perhaps represent sequelae of a ruptured appendicitis, as the appendix was not well visualized on the study
  • Testicle- possibly a necrotic testicle? Admitted to PICU overnight for monitoring, observation for AM appendectomy Diagnosis: Ruptured Appendix with abscess drainage Admitted to PICU postoperatively Treated with Clindamycin, Zosyn Tranferred to B3 on HD #2 Wound Cx: Ecoli, strep viridans, provetella, bacteroides Testicular Biopsy:benign fibrovascular tissue containing small amounts of skeletal muscle w/ mild acute and chronic inflammation Appendix Biopsy: supparative 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 D/C’d to home on HD# 7 w/ surgery and urology follow-up
  • Study done looking at closed medical malpractice claims from St. Paul Fire and Marine Insurance Co and Specturm Emergency Care, Inc were examined from 1984-1989 reviewed 66 cases of misdiagnosis of appendicitis resulting in litigation.
  • Initial reviews with radiology were read as RML pneumonia and AXR was read as ileus c/w Viral Gastroenteritis or current illness. Primary Care physician also concerned about the loop in RLQ c/w appendicitis, or other intestinal process.

Transcript

  • 1. Pediatric Case Management The Children’s 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
  • 4. 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 Hirshprung’s 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, 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
  • 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 @ 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/H=12.9/36.1; Plts 286
    • CMP WNL
  • 11. Right Testis Left Testis Testicular Ultrasound
  • 12. ER Management, cont’d.
    • 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 60-70’s, atropine given, HR> 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
  • 16. 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
  • 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.
  • 18. Age Related Differences in the Presentation of Appendicitis
    • Neonates (birth – 30 days)
    • Infancy
    • Preschool
    • School-aged
    • Adolescent
  • 19. 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).
  • 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 ; 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
  • 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 25 th , 2005
  • 25. 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
  • 26. 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
  • 27. 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 < 2sec
      • Lungs: CTA b/l
      • Abd: normoactive BS, generalized tenderness , soft, + guarding ,  RT, masses or HSM
  • 28. 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
    11.7 13.1 37.1 135 141 4.6 102 20 10 0.3 10.7 N 83 L 13.9 M 2.9 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%, Con’t Ceftriaxone,NPO
    • HD#1: 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
  • 31. 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
    • HD#3 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. 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
  • 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
      • <15% pt with triad
      • 20% no obvious pain
      • 1/3 do not pass blood or mucus
      • Pain alone
  • 39. 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%
  • 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 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
  • 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