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Pediatric Case Management The Children's Hospital at Sinai

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Pediatric Case Management The Children's Hospital at Sinai

  1. 1. Pediatric Case Management The Children’s Hospital at Sinai October 25, 2005
  2. 2. October Cases-Ward <ul><li>6 month old female with h/o NEC, admitted with bilious emesis (morbidity) </li></ul><ul><li>5 yo male with scrotal pain (morbidity) </li></ul>
  3. 3. October Cases-ER <ul><li>17 year old with Sinusitis transferrred out for pneumocephalus </li></ul>
  4. 4. October Cases-PICU <ul><li>17 yo female with CML (mortality) </li></ul><ul><li>4 month old with hepatoblastoma found to have a femur fracture during hospitalization (morbidity) </li></ul><ul><li>15 yo female unresponsive (morbidity) </li></ul>
  5. 5. October Cases-NICU <ul><li>Ex 25 5/7 premature infant with IUGR and respiratory failure (mortality) </li></ul><ul><li>Ex 29 week premature infant transferred from outside hospital with acute abdominal perforation and NEC (mortality) </li></ul><ul><li>FT infant re-admitted with bilious emesis found to have Hirshprung’s Disease (morbidity) </li></ul>
  6. 6. Case Management 5yr old with left scrotal pain Kennon Harris, MD October 25, 2005
  7. 7. CC: R testicular swelling <ul><li>5yo male presented to ED w/ 3 day hx of R testicular pain/swelling </li></ul><ul><li>hit by brother in groin area approx 13 days pta </li></ul><ul><li>pain beginning 3 days later </li></ul><ul><li>developed nausea, vomiting; mild diarrhea; no fever </li></ul><ul><li>Decreased appetite </li></ul><ul><li>Noted to be “hunkered over” when walking </li></ul>
  8. 8. History, cont’d . <ul><li>PMH: s/p L blephoraplasty </li></ul><ul><li>Imm: UTD; received Hep A 10 days pta </li></ul><ul><li>Meds: none </li></ul><ul><li>All: none </li></ul><ul><li>Soc Hx: recently started Kindergarten </li></ul><ul><li>Fam Hx: lives w/ parents and 6 siblings </li></ul>
  9. 9. Emergency Department <ul><li>T37.3 HR92 RR18 BP101/66 O2 sat98% RA wt20.6 kg </li></ul><ul><li>Gen: Anxious, NAD Pain score: 4 </li></ul><ul><li>Abd: +periumbilical tenderness, no rebound, no guarding; no rectal performed; nml bs; no hsm </li></ul><ul><li>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 </li></ul><ul><li>Ext: NT, nml ROM </li></ul><ul><li>Neuro: no deficits </li></ul>
  10. 10. Emergency Department <ul><li>NPO </li></ul><ul><li>NS bolus (20 cc/kg), then IVF @ M </li></ul><ul><li>Emesis X 1 </li></ul><ul><li>Labs: </li></ul><ul><li>Urine dip: 1.015/7.5/neg; </li></ul><ul><li>WBC 18.5K ( 70.6 N 13.6 L 5.7 E) </li></ul><ul><li>H/H=12.9/36.1; Plts 286 </li></ul><ul><li>CMP WNL </li></ul>
  11. 11. Right Testis Left Testis Testicular Ultrasound
  12. 12. ER Management, cont’d. <ul><li>Urology consult: </li></ul><ul><li>Dx: Testicular torsion vs. Hematoma </li></ul><ul><li>Taken to OR for b/l scrotal exploration </li></ul>
  13. 13. Hospital Course <ul><li>Intraop Findings: L testical abnormal in appearance, but pink w/ bleeding parts; thickened but with no gross pathology, no hernia. </li></ul><ul><li>Biopsy taken </li></ul><ul><li>Surgical consult </li></ul><ul><li>PACU: HR 60-70’s, atropine given, HR> 95 </li></ul><ul><li>Admitted to PICU postoperatively for close monitoring </li></ul>
  14. 14. CT abd/pelvis w/ contrast: <ul><ul><li>R lower quadrant abscess w/ associated L scrotal abscess (may represent sequelae of ruptured appendicitis, as appendix not well visualized) </li></ul></ul><ul><ul><li>Prominence of small bowel loops which may represent evolving ileus or sbo </li></ul></ul><ul><ul><li>B/L lower lobe infiltrates </li></ul></ul>
  15. 15. Hospital Course <ul><li>Admitted to PICU monitoring/observation </li></ul><ul><li>Operative Diagnosis: Ruptured Appendix with abscess </li></ul><ul><li>Admitted to PICU postoperatively </li></ul><ul><li>Treated with Clindamycin, Zosyn </li></ul><ul><li>Wound Cx: Ecoli, strep viridans, provetella, bacteroides </li></ul>
  16. 16. Hospital Course, cont’d. <ul><li>Testicular Biopsy: benign fibrovascular tissue containing small amounts of skeletal muscle w/ mild acute and chronic inflammation </li></ul><ul><li>Appendix Biopsy: suppurative appendicitits and periappendicitis w/perforation and florid fibrinopurulent exudate formation </li></ul><ul><li>Repeat testicular U/S on HD # 4: hypoechoic L testicle surrounded by a hypervascular periphery </li></ul>
  17. 17. Challenges In Correct Diagnosis of Appendicitis <ul><li>Misdiagnosis rates range from 28-57% for children 12 years or older </li></ul><ul><li>Nearly 100% for those 2 years or younger </li></ul><ul><li>Among the five leading causes of litigation against emergency room physicians </li></ul><ul><li>Appendiceal perforation is nearly universal in children 3 yrs or younger. </li></ul>
  18. 18. Age Related Differences in the Presentation of Appendicitis <ul><li>Neonates (birth – 30 days) </li></ul><ul><li>Infancy </li></ul><ul><li>Preschool </li></ul><ul><li>School-aged </li></ul><ul><li>Adolescent </li></ul>
  19. 19. Initial misdiagnosis in childhood appendicitis <ul><li>Gastroenteritis 42% </li></ul><ul><li>Upper Respiratory Tract infection 18% </li></ul><ul><li>Pneumonia 4% </li></ul><ul><li>Sepsis 4% </li></ul><ul><li>UTI 4% </li></ul><ul><li>Encephalitis/Encephalopathy 2% </li></ul><ul><li>Febrile Seizure 2% </li></ul><ul><li>Blunt Abdominal Trauma 2% </li></ul><ul><li>Unknown 22% </li></ul>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. 20. Challenges In Correct Diagnosis of Appendicitis <ul><li>Laboratory Adjuncts </li></ul><ul><ul><li>WBC Count </li></ul></ul><ul><ul><li>CRP </li></ul></ul><ul><li>Radiologic Evaluation </li></ul><ul><ul><li>Plain radiographs </li></ul></ul><ul><ul><li>Radioisotope-labeled WBC scanning </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>CT*-Gold Standard </li></ul></ul><ul><li>Scoring Systems </li></ul><ul><ul><li>MANTRELS score in children-not accurate </li></ul></ul>
  21. 21. Challenges In Correct Diagnosis of Appendicitis <ul><li>Patient most likely to have missed diagnosis of appendicitis on initial ED visit: </li></ul><ul><ul><li>No “classic” signs </li></ul></ul><ul><ul><li>Pain, but no nausea/vomiting </li></ul></ul><ul><ul><li>No rectal exam performed </li></ul></ul><ul><ul><li>Administration of a narcotic pain medication </li></ul></ul><ul><ul><li>Diagnosis of gastroenteritis </li></ul></ul><ul><ul><li>No follow-up examination within 12-24 hrs. </li></ul></ul>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. 22. References <ul><li>Pollack ES. Pediatric Abdominal Surgical Emergencies. Pediatric Annals ; 25:6, August 1996: 448-457. </li></ul><ul><li>Rothrock, SG, Pagane, J. Acute Appendicitis in Children: Emergency Department Diagnosis and Management. Annals of Emergency Medicine ; July 2000: 39=50. </li></ul><ul><li>Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of Acute Appendicitis: Common Features After Litigation. The American Journal of Emergency Medicine ; July 1994: 397-402 </li></ul>
  23. 23. Topics for Discussion <ul><li>Work up for child with periumbilical tenderness and testicular pain </li></ul><ul><li>Relationship between intra-abdominal findings and testicular compartment </li></ul>
  24. 24. Case Management Conference Brenda Figueroa, MD October 25 th , 2005
  25. 25. TG 2 y/o girl with abdominal pain and vomiting <ul><li>HPI: </li></ul><ul><ul><li>Sent to Sinai’s Peds ER by PMD </li></ul></ul><ul><ul><li>1 day abdominal pain,R sided, intermittent, intense, lasting 1 min every 5 min </li></ul></ul><ul><ul><li>No aggravating or relieving factors </li></ul></ul><ul><ul><li>Vomiting “too many times to count” NB,NB, preceded by pain </li></ul></ul><ul><ul><li> sleepiness, nl appetite,  fever or cough </li></ul></ul><ul><ul><li>Last BM 1d PTA nl </li></ul></ul>
  26. 26. History <ul><li>PMHx: </li></ul><ul><ul><li>Ex- 32wks born C/S in NY </li></ul></ul><ul><ul><li>prenatal labs neg; </li></ul></ul><ul><ul><li>NICU stay 1 mo for prematutity </li></ul></ul><ul><ul><li>“ bladder infection” 2mo ago </li></ul></ul><ul><li>Immunizations: UTD </li></ul><ul><li>Allergies: NKDA </li></ul><ul><li>Family Hx : non-contributury </li></ul><ul><li>Soc. HX: </li></ul><ul><ul><li>Lives with parents , sister, aunt & uncle </li></ul></ul><ul><li>Personal Hx : </li></ul><ul><ul><li>Development age appropiate </li></ul></ul>
  27. 27. ER Physical Exam <ul><li>VS : T 35.1 HR 130 RR20 PO2 99% RA </li></ul><ul><ul><li>BP 131 / 67 Pain scale 4/10 </li></ul></ul><ul><ul><li>Gen App: sleepy but arousable </li></ul></ul><ul><ul><li>HEENT:  nasal dc,nl pharynx, TMI,  LAD </li></ul></ul><ul><ul><li>CVS: nl S1S2  murmurs, Cap refill < 2sec </li></ul></ul><ul><ul><li>Lungs: CTA b/l </li></ul></ul><ul><ul><li>Abd: normoactive BS, generalized tenderness , soft, + guarding ,  RT, masses or HSM </li></ul></ul>
  28. 28. Management <ul><li>NS bolus 20cc/kg X 2, then M </li></ul><ul><li>Zofran 2 mg IV X 1 </li></ul><ul><li>CXR & AXR </li></ul><ul><li>Labs: </li></ul><ul><li>Ceftriaxone 1 G IV X 1 </li></ul><ul><li>Admitted to B3 Peds </li></ul>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. 29. Imaging Studies Single dilated loop of bowel and air fluid level, no specific evidence of obstruction No infiltrates or effusions
  30. 30. Hospital Course B3 <ul><li>VS T 36.5 HR 103 RR 20 BP 121 / 72 POx 98% </li></ul><ul><li>Exam: Sleepy but arousable, Lungs CTA, Abd exam soft, NT, ND, nl BS,  masses </li></ul><ul><li>Plan: Rehydration schedule for 5%, Con’t Ceftriaxone,NPO </li></ul><ul><li>HD#1: HR 88-124 RR 20-24 BP 121-129/67-72 Pain 0-4 </li></ul><ul><ul><li>Resp :  distress, CTA,  O2 requirement. Lateral CXR obtained showing no evidence of pneumonia </li></ul></ul><ul><ul><li>GI: nl exam , emesis X 3 sm amount, NBNB, advanced to CLD did not tolerate </li></ul></ul>
  31. 31. Hospital Course, continued <ul><li>HD #2 HR 96-138 RR 22 -32 BP 78- 125 /44- 74 Pain 0-4 </li></ul><ul><li>GI: emesis X 4 sm NBNB, Abd sl distended , soft, (+)BS, not tolerating PO </li></ul><ul><li>HD#3 T 35.8 HR 125 RR 28 BP 107/81 Pain 0-4 </li></ul><ul><li>GI: emesis x 6 bilious c/o abdominal pain “squirms and points to R side” Abd: distended , soft,  masses,  BS </li></ul><ul><li>AXR/AUS performed, NGT placed </li></ul>
  32. 32. Images Moderate dilatation of small bowel loops, with fluid levels c/w small bowel obstruction
  33. 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. 34. OR Findings & subsequent progress <ul><li>Reduction was attempted with barium enema </li></ul><ul><li>Exploratory laparotomy </li></ul><ul><ul><li>Reduction of ileo-ileocolonic intussusception </li></ul></ul><ul><ul><li>Bowel viable </li></ul></ul><ul><li>Observed in PICU </li></ul><ul><ul><li> emesis, NGT dc </li></ul></ul><ul><li>HD#4 To B3 </li></ul><ul><ul><li>Tolerated PO, + BM </li></ul></ul><ul><li>DC home HD#5 </li></ul>
  35. 35. Intussusception in Children <ul><li>One of the most common causes of acute intestinal obstruction </li></ul><ul><li>A segment of bowel invaginates into the distal bowel </li></ul><ul><li>Results in venous congestion & bowel wall edema </li></ul><ul><li>Obstruction of arterial blood supply, bowel infarction, perforation, death </li></ul>
  36. 36. Incidence & Etiology <ul><li>0.3-2.5 cases per 1000 live births </li></ul><ul><li>mortality uncommon </li></ul><ul><li>case fatality rates up to 50% in developing countries </li></ul><ul><li>idiopathic cause most cases </li></ul><ul><ul><li> seasons of viral gastroenteritis  </li></ul></ul><ul><ul><li>Associated with rotavirus vaccine </li></ul></ul><ul><li>lead point > common in children >5yrs </li></ul>
  37. 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. 38. Clinical Manifestations & Physical Findings <ul><li>intermittent, severe, crampy abdominal pain </li></ul><ul><li>Vomiting, initially NB, becomes bilious with progression </li></ul><ul><li>Between episodes child behaves normally </li></ul><ul><li>As it progress lethargy appears </li></ul><ul><li>“ currant jelly” stools </li></ul><ul><li>Sausage shaped abdominal mass </li></ul><ul><ul><li><15% pt with triad </li></ul></ul><ul><ul><li>20% no obvious pain </li></ul></ul><ul><ul><li>1/3 do not pass blood or mucus </li></ul></ul><ul><ul><li>Pain alone </li></ul></ul>
  39. 39. Clinical Case definition for the diagnosis of acute intussusception <ul><li>Major Criteria </li></ul><ul><ul><li>Evidence of intestinal obstruction </li></ul></ul><ul><ul><li>Features of intestinal invagination (1 or more) </li></ul></ul><ul><ul><li>Evidence of intestinal vascular compromise </li></ul></ul><ul><li>Minor Criteria </li></ul><ul><ul><li>Age <1 yr & male </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Pallor </li></ul></ul><ul><ul><li>Hypovolemic shock </li></ul></ul><ul><ul><li>Abnormal but non-specific bowel pattern of x-ray </li></ul></ul><ul><li>Definite -surgical/radiological criteria </li></ul><ul><li>Probable -2 major, or 1 major 3 minor </li></ul><ul><li>Possible - 4 or more minor </li></ul>Journal of Pediatric Gastroenterology & Nutrition. 39(5):511-518, November 2004 Associated with spasm Sensitivity 97% Specifity 87-91%
  40. 40. Diagnosis & Treatment <ul><li>High index of suspicion </li></ul><ul><li>AXR </li></ul><ul><li>US </li></ul><ul><li>CT scan </li></ul><ul><li>Contrast studies </li></ul><ul><li>Barium enema reduction </li></ul><ul><li>Air contrast </li></ul><ul><li>Surgery </li></ul>
  41. 41. References <ul><li>Seiji K, MD Mohamad M.,MD Intussusception in children Uptodate april 2005 </li></ul><ul><li>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 </li></ul><ul><li>Hong-Yuan, H., Mdet al. Viral etiology of intussusception in taiwanese childhood Pediatric Infectious Disease Journal Oct. 1998 17:10 893-898 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Blakelock RT, Beasley SW, The clinical implications of non-idiopathic intussusception Pediatr Surg Int . Dec 1998 14:3 163-167 </li></ul><ul><li>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 </li></ul>
  42. 42. Points for Discussion: <ul><li>Initial interpretation of imaging vs. final reading </li></ul><ul><ul><li>Documentation of multiple discussions re: film </li></ul></ul><ul><li>No physical exam findings c/w pneumonia </li></ul><ul><li>Importance of index of suspicion in child with intermittent abdominal pain and vomiting </li></ul>

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