ED morbidity and mortality conference Date: 2006/09/26 R3 黃傑廷 Guided by VS 吳孟書

Initial triage and general data 2006-09-11 00:47 (0hr 0mins) T:36, P:109, R:26, SaO2: 99% E4V5M6 檢傷分類: 3級 病患主訴因腹痛,臉色蒼白,外院轉診 Name: 江X皓 Chart No:20997400 Age: 4 y/o 3 m/o

Chief compliant Severe abdominal pain with irritable crying tonight

Present illness Abdominal pain with irritable crying since last night (9/10 10:pm) Non-bilious vomiting x 4 times Mild fever around 38 degree at home No diarrhea No URI recently 一開始去LMD,告之可能為腸套疊

Personal History G1P1, twin B, BBW:2000gm, GA:38wks, C/S due to twin pregnancy Newborn screen: negative finding Allergy: no schedule Vaccine: as schedule Development: no delay No admission or operation history

Physical Examination Appearance: weakness, awake Breathing: OK Circulation: pink, no cyanosis HEENT: throat no injection, ear-drum: ok Chest: bil. Clear, RHB without murmur Abdomen: soft, mild distended, diffuse tenderness, no muscle guarding Extremity: free, no skin rash, CRT < 1 sec

What clinical histories and physical examinations should we approach about abdominal pain in a 4 y/o child?

Clinical history Presence and character of abdominal pain History and character of emesis Bowel history Systemic symptoms Associated symptoms attributable to the lower respiratory tract or urinary system Past medical history

Physical examination Gaining the child's confidence will often allow a better exam! Observing the patient's ability to move Repeat exams, especially if the child falls asleep, might prove invaluable Inspection and observation Abdominal palpation Auscultation Examination of nonabdominal areas Rectal examination

Summary this patient Sudden onset cramping pain, diffuse, intermittent or persistent ? Vomit (+), several times, non-bilious Bowel history: no diarrhea Systemic symptoms: crying, mild fever Associated symptoms: no cough, no dysuria Past medical history: denied Trauma history ? Digital examination ?

4 y/o boy with abdomen pain, what’s your D/D?

The etiology of abdominal pain Under 2 years Appendicitis Colics (first 4 months) Congenital anomalies Gastroenteritis Incarcerated hernia Intussusception Malrotation Metabolic acidosis Obstruction Sickle cell crisis Toxins Urinary tract infection Volvulus 2-5 years Appendicitis DKA Gastroenteritis Hemolytic-uremic syndrome Henoch-Schonlein purpura Incarcerated hernia Intussuscetion Metabolic acidosis Obstruction Pneumonia Sickle cell crisis Toxins Trauma Urinary tract infection Volvulus Tinitinalli p.184 table 127-1

The etiology of abdominal pain 6-11 years Appendicitis DKA Functional Gastroenteritis Henoch-Schonlein purpura Incarcerated hernia Inflammatory bowel disease Obstruction Peptic ulcer disease Pneumonia Sickle cell syndrome Streptococcal pharyngitis Torsion of ovary or testicle Toxins Trauma Urinary tract infection Over 11 years Appendicitis Cholecystitis DKA Dysmenorrhea Ectopic pregnancy Functional Gastroenteritis Incarcerated hernia Inflammatory bowel disease Obstruction Pancreatitis Peptic ulcer disease Pneumonia Pregnancy Sickle cell syndrome Torsion of ovary or testicle Toxins Trauma Urinary tract infection Tinitinalli p.184 table 127-1

Which is possible cause ? 2-5 years Surgical condition: Intussuscetion: intermittent pain(-), echo? Ruptured appendicitis Bowel obstruction: with fever? Gangrene? Incarcerated hernia: palpable mass? Complete PE needed Trauma: history? Volvulus: age? Medical condition: Gastroenteritis: no diarrhea, but still possible Pneumonia: no cough, CXR is needed DKA: F/S might be checked Urinary tract infection: U/A might be checked Hemolytic-uremic syndrome: CBC/DC, BUN/Cr ? Toxins: history ? Sickle cell crisis: no history Henoch-Schonlein purpura: no purpura, no skin rash X 2-5 years Surgical condition: Intussuscetion Ruptured appendicitis Bowel obstruction Incarcerated hernia Trauma Volvulus Medical condition: Gastroenteritis Pneumonia DKA Urinary tract infection Hemolytic-uremic syndrome Toxins Sickle cell crisis Henoch-Schonlein purpura

Initial oder 95-9-11 00:57am (0hr 10mins) CBC/DC CRP Blood culture Na K AST ALT Sugar D5S1/4 run 50ml/hr

Lab data WBC 10900 Seg 82% Lym 16% Mono 1.0% RBC 6.02 Hb 16.7 Hct 49.2 Plt 323k Sugar 278 AST 37 ALT 17 K 3.4 Na 142 CRP 12.7

LMD KUB 9/10 23:47

95-09-11 02:53am (2hrs 06mins) U/A Ketone body ABG stat Arrange air reduction admission Is it OK?

Consider order CXR (standing) Renal function (BUN/Cr) air reduction after abdomen echo or more clear about diagnosis

U/A ABG Ketone body: negative Nitrite: negative PH: 7.400 Protein: negative Ketone: negative Glucose: 0.300 RBC:3 WBC:3 Ketone body: negative ABG PH: 7.400 PaCO2: 35.7 PaO2: 75 HCO3: 21.6 SBE: -3.2 SAT: 98.3

Air reduction 9/11 5:37am

Air reduction

Report: No evidence of colonic obstruction, so the intussusception is not likely

Still abdominal pain… 95-9-11 09:37am (08hrs 50mins) BT:39 HR:148 RR:24 BP:113/67 Diclofenac supp 95-9-11 11:26am (10hrs 39mins) BT: 39.4 Vomit x 1 95-9-11 13:00 (12hrs 13mins) Admission to ward

Do you agree? What happened to this patient? If you were duty Dr, what would you do?

Peritoneal sign + fever -> surgical abdomen is highly suspected More clear history and physical examination should be obtained! Consider further image study Abdominal echo Abdominal CT

95-9-11 afternoon Admission to ward… 95-9-11 13:50 (13hrs 03mins) Admission 95-9-11 14:40 (13hrs 53mins) Abdomen echo Ascites, bowel dilation in proximal GI tract, rectum collapsed, gaseous abdomen r/o pneumoperitoneum 95-9-11 14:50 (14hrs 03mins) BT:40 P:180 RR:31 BP:110/80 oximeter:94% F/S: 145mg/dl Transfer to PICU F/U plain abdomen

Small bowel dilatation 9/11 4:36pm Small bowel dilatation

Impression r/o ischemic bowel r/o ileus with bowel obstruction Consult 小兒外科

OP note Congenital mensenteric defect about 7*7 cm at 140cm distal to Treitz ligment with entrapped small bowel, volvulus and bowel gangrene 300cc turbid ascites Resection of the gangrene small bowel about 30cm (140-170cm distal to Treitz ligment), the residual ileum about 50cm End ileostomy was performed at 140cm distal to Treitz ligment, and the distal ileum was closed by 2 layers closure

Admission course 09-11: operation and admit to PICU 09-16: extubation and transfer to oridnary ward 09-19: condition stable, MBD and OPD F/U

Key point Adequate history and PE before your diagnosis and management The cause of the acute abdomen varies depending on the age of the child, and we should always keep surgical condition in mind