with Shilpa Patel on the Hot Seat
10 mo boy with history of trisomy 21 presents with vomiting. The patient was in his previous state of good health when he began having persistent emesis starting about 12 hours prior to arrival. It happened about 10 times in several hours. Initially the emesis was non-bloody, non-bilious. The last emesis was “green tinged”. He has had 1 wet diaper in the last 8 hours and does not want to drink much. The last emesis was 2 hours ago, mucous, no blood, no bile. He had loose stool this morning, non-bloody.
ROS: Afebrile, no rashes/congestion/URI symptoms/cough/hematochezia
PMH: Trisomy 21, no known complications or surgeries
FHx: None
Exam
T 36 HR 135 RR 30 BP 85/55 Wt 8.7 kg
Alert, appropriate, slightly tired but responsive, interactive
HEENT: PERRL, NC/AT, AF closed, neck supple, no LAD, dry MMM
Chest: CTAB
CV: RR, no murmurs, CRT ~2 sec
Abd: soft, ND/NT, no palpable masses, no organomegaly, no hernia
Based on his decreased UOP and poor PO, he was given a normal saline bolus.
It is now 2 am.
Questions for you: (click "Vote" to record your answers and see what others said)
He is back from X-ray, the patient's x-ray is below:
Radiology is equivocal on this x-ray. The patient's abdominal exam is unchanged.
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I guess one of the questions here is if you should treat a child with Trisomy differently than others at this age. 10mo vomiter....sure, prime age for intussusception. But you're describing a soft abdomen, non-irritable child with a pretty benign looking XR although only one view visualized. The studies for XR and intussusception use a 3 view approach, here we tend to do 2 (supine, LLD). Personally, I get a BMP and a urine for any kid i give a bolus. I think it's difficult to accurately assess moderate dehydration. Mild is easy, severe is easy. but the kids in the middle sometimes fool me, especially at this age. Electrolyte abnormalities and urine ketosis give me an idea of how difficult it will be to rehydrate a child. And sodium boluses are not necessarily benign, so it's important to know your sodium and renal status before giving a second in the absence of shock, etc. Urine can be a bag and a dip. Not sure what else to say here. if the kid tolerates PO and continues to have a soft belly and not be fussy, he goes home. The trisomy might get a slightly longer PO challenge because of behavioral/developmental limitations. And trisomy kids are more likely to get just about everything, so i treat them gingerly....But sounds like a kid who is going to fly.
ReplyDeletehey, don't forget to do a GU exam in kids with vomiting!!!! you forgot to list one :( inguinal hernias, torsion, etc. these things get missed in vomiting infants !
Three red flags for this case are:
ReplyDelete1. Down syndrome
2. One bilious emesis
3. Equivocal Xray
#1 - Down syndrome kids have blunted catecholamine responses in general, so clinical exam in these kids is key as your "normal HR" can occasionally be misleading. If such a child is already moderate dehydration on presentation, he's probably staying ETU at a minimum (esp at 2am, with somewhat lethargic caregivers) until he looks completely back to baseline and drinking like a champ. If failing ETU, likely short stay PHAST.
#2 - Bilious emesis. The Hx says that the last emesis both was and wasn't bilious... I've gotten that hx before too,from two different parents. Hmmm.... One worries about malrotation, partial/complete obstructions in Trisomy 21 or any aged children with bilious emesis - with high suspicion, an upper GI series would be comforting but might not be necessary at this early stage. If, with passing time in the ER or hospital, he has more definitive (have parents save the emesis) bile stained emesis, then get the study, surgery consult, NPO/IVF...
#3 - Equivocal xray... Equivocally how? I think I see air in the distal rectum (plus child stooled this morning) but can't tell for sure. If the radiology resident wasn't sure about something, I'd talk it over with them and if they were uncertain but worried about something more serious that we couldn't see ourselves on xray, then I'd see if the attending radiologist could weigh in.
Zofran? Normal heart per history. Likely has an EKG on record - if no Long QT, then happy to prescribe it for a 3 day course with specific return to ED instructions.
I agree with Dave and Paul. I don't always get a BMP on my vomiting kids, especially if it has not been that long of a duration, but it's something I consider. Overall, I'd treat this kid more gingerly given what Paul and Dave mentioned and have a higher standard (po intake, appearance) for him to be discharged than for other kids. Given the time of day, I would let them hang out in ETU, get some IVF and re-try the PO in the morning. This also gives the kid more time to show his true "colors" (pun intended).
ReplyDeleteAsha