Hot Seat #22 Denouement: Persistent vomiting

by Sonny Tat, Children's National
with Pavan Zaveri, Children's National, on the Hot Seat


The Case

This is a case of of a 7 week-old boy with one week of projectile vomiting and two normal abdominal ultrasounds. For the complete case presentation, click here.

Clinical Pearls
Thank you to Joelle, Theresa, Jennifer, Dewesh, and Dave for your clinical perspectives on red flags, discharge and admission criteria, and follow-up considerations. And thank you to Pavan for the larger discussion on risk tolerance in your Hot Seat response. Click here to read them in full.

• "I think about if I got this kid on signout with the info above. Despite the fact that he has had a po trial and now not having further projectile emesis, I can't help but think that something looked awry for you to give a bolus in the first place." -Joelle, Children's National


• "Additional history I'd like to obtain: (1) change in weight between 2 PMD visits -- if gaining weight, I'd be much less concerned; (2) has there been progression of symptoms over the course of the week?; (3) what is meant by term "projectile"?, is it the same as that witnessed in the ED?; (4) did the "limited" US in the ED assess the pylorus specifically and the kidneys?" -Dewesh, Children's National
  
• "I first want to know if the child is losing weight. Vomiting or spitting up in the absence of clinical dehydration and weight loss is totally uncompelling. Without weight loss, I think of early pyloric, overfeeding, colic, mild-mod GER. With weight loss, I want to expand my ED evaluation. Think about things like: milk protein enterocolitis, malrotation, upper duodenal obstruction, metabolic causes, renal disease, late pyloric, severe GER, etc." -Dave, Children's National
  
• "The differential is as above: anatomic anomalies of GIT, metabolic abnormalities, increasing intracranial pressure." -Jennifer, Children's National
• "But then don't forget about the fussiness. I try to accumulate enough data to say that it's not intracranial. Fontanelle? Head Circumference? Tachycardia/Bradycardia? Not calming down? fussiness and vomiting can be colic......or aqueductal stenosis, or post-hemorrhagic hydrocephalus, or abusive head trauma. So don't forget about the head!" -Dave, Children's National
  
• "If the pmd couldn't reassure me or gave me addn'l hx that was concerning I'd start with an UGI." -Theresa, Children's National
  
• "This baby could be discharged after the one feed if if if... the baby hasn't been losing weight; the fussiness is not irritability (can't be consoled by parent); there aren't additional symptoms; I can talk to the PMD to check on growth parameters." -Jennifer, Children's National
  
• "I am leaning towards a period of observation for at least 24hrs to observe parental interaction, a few feeding episodes, and to get that upper GI." -Joelle, Children's National
  
• "I worry about sending home a fussy 7 week-old who has been vomiting for a week now after numerous (I count 3) MD visits." -Dewesh, Children's National
  
• "I feel quite strongly that if a baby this young got dehydrated enough to require a fluid bolus, the baby should be kept in house. GER can cause weight loss and so probably dehydration, but this is rare." -Jennifer, Children's National
  

Here's how you answered our questions:

What criteria will you sign out to determine when this patient should be discharged from the ED?

No one used just a second ED feeding without vomiting as discharge criteria. Someone said he or she had another discharge criteria but did not specify here so it will remain their secret.

If you do NOT discharge this patient, which of the following imaging studies would you choose FIRST?

If you did NOT pursue further workup, how much longer would you observe without a clinical change before discharging?

Wide distribution of answers. No one was in the 'tweer observation campe between 9-11.9 hours or 12-18 hours.

The Hot Seat Response
by Pavan Zaveri, Children's National

Ahh, the 7 week old...older than a newborn, but not quite a "reliable" infant (>3 mos). A case like this always is a dilemma wanting to ensure you're not missing something but not overdoing it. The others have gone through the differential quite nicely and I have little more to add there.

There has also been a great commentary on what "fussy" means, how important connecting with primary care is and the challenge of multiple visits. So, what can I impart here?

A commentary on risk: As you can see all of us draw our line in the sand at very different places. At this time, I'd like to share an exercise Christina had the faculty do at a recent retreat at her house: Place yourself somewhere on the continuum for a variety of concepts. Most interesting was risk-averse and risk-tolerant. What surprised me most was that experience (ie years post-fellowship) did not necessarily correlate to anything. There are many factors that influence where we fall on this continuum: personal experiences, training environments (residency and fellowship), mentors (or, broadly who we look [up] to), malpractice cases, depth of reviewing the literature, understanding of statistics and many more. What's more important to keep in mind is that any of these factors can push us in either direction on this line. And, as you move along you can look at the same info incorporating something new and flip your position on a given topic.

We all will set our risk-tolerance at a certain place, test/evaluate/reassess to that point to make a decision to discharge, admit or keep watching. For this infant, it is a case of it depends. Fussy? Projectile? Head size? Follow-up? Rapport? Setting all of these straight also affect your tolerance of risk. Once all these i's are dotted and t's are crossed, it may very well be discharge. But, I personally would probably go down the UGI route to ensure there's not anatomic concerns (duodenal web, etc) before discharging and a good talk with this child's PMD, if possible, not just the Kaiser hospitalist who will put a note in the system...

Let's see what turns out.

The Denouement
by Sonny Tat, Children's National

Following the negative abdominal ultrasound (#2 total), the patient was observed for two hours and noted to have normal feeding without projectile vomiting. We discussed the possibility of an upper GI study to evaluate for malrotation. Radiology did not believe it was indicated based on the ultrasound results. The patient was clinically stable at this time. We discussed the follow-up plan with the PMD for the following day and discharged the patient home.

The following day at the follow-up visit, the PMD noted a bulging fontanelle, and significant increase in head circumference from two days prior (2 cm) and parents reported persistent intermittent emesis. The patient was referred to our ED for a head ultrasound after a phone discussion with neurosurgery.

The head ultrasound was normal. We proceeded to a head CT, which showed bilateral subdural hematomas, small right frontal and temporal subarachnoid hemorrhage, and mild diastasis of the sutures (images below).

The patient was admitted to the ICU and went to the OR for burr hole drainage. The non-accidental trauma work up was negative for occult fractures, other injuries, or coagulopathy. The patient was discharged to the parents after one week. In Child Protection follow-up weeks later the patient was noted that the patient had recovered well.

According to Child Protection notes, while NAT is the most likely etiology, there is no history of trauma. At the last Child Protection visit factor IX, fibrinogen, and thrombin time were still pending and a glutaric aciduria had not yet been sent. The family was planning to move to Texas so we have no further follow-up.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations but is on leave until September. This week's case was guest edited by Paul Mullan, faculty at Children's National. We welcome your commentary.