Kiwiology Posted November 19, 2013 Author Posted November 19, 2013 So the kid looks at her bellybutton. What happens? Any illness in the familiy recently? Kid fussy, or kind of blah and wanting to hide? No recent family illnesses. Hard to tell really, she just wants to stay in bed, mum said previously when she wanted to go to the toilet that she had to physically pick her up and take her to the bathroom because she of how she felt. Could be anything. This is the most vague scenerio I've ever seen This is a real case (slightly modified). If you look at several of the findings thus far they should be telling you this is a person who is likely to be subtly very unwell. Consider the source, no offense but honestly, I can't understand half of what he's saying half the bloody time. Fair enough mate, now hand me that thingamadongle there, this bloke looks like he's a bit crook, gonna have a fossick in his noggin .... Well I've tried to get more info, just got more questions. This scenero is no fun What else would you like to know? I answered your questions. If you don't take the same prescription meds as he does , nothing makes sense. Oh stop it you 1. The DDx is so general at this point. It could be infections, poisoning, endocrine, etc. 2. The photophobia and respiratory rate are concerning. The BGL is a little towards the low side. This is 911, you call we haul. 3. Nothing to say this pt needs to be made a highest priority pt. 4. Rectal temp and more info from the mother You can skip an actual diagnosis I guess, it's less important than recognition that something is awry with this kid The photophobia is hard to pin down really; it could be photophobia or it could be a 3 year old kid who doesn't like being around strange ambos. The respiratory rate should be concerning. A raised respiratory rate in the absence of an obvious cause should be a flag for further investigation. I hypothesise it is often a sign of inadequate tissue perfusion and the beginnings of anaerobic respiration thus we get a raised respiratory rate in an effort to excrete excess CO2 when the lactate is converted into whatever lactate is converted into, help me out here Emergentologist, your BSc in Biochemistry (Cums a Lot) will mean you know far more about that than I do. The BGL is low, for us it is quite low, our normal is 4 mmol/l (80 mg/dl) and in children this is often sign of a significant underlying infection. Temperature is a little bit high as well but it's clinical significance is debatable until the cows come home. It is also significant that when she wanted to go to the toilet the mother had to carry her. Inability to mobilise normally (in the absence of an obvious cause) is probably not a good thing. I think the patient needs to be seen by a Doctor tonight, doesn't have to be immediately but should be with an hour of arriving at ED. I wouldn't give her any treatment in the pre-hospital setting. This is a real case (slightly modified) where the patient was left at home and died about 12 hours later of meningococcal septicaemia. While there was nothing immediately obvious in the history and exam that pointed to meningococcal septicaemia there were several signs (above) that the child was compensating for some significant underlying problem that needs further investigation. Many people would "explain this away" as the flu or a cold or even gastro. In the absence of diarrhoea some 16 hours after feeling sick then this isn't gastro and with no sore throat or cough after the same time period it's not the flu. Thanks for playing, pass GO, collect $200, go straight to ED, collect your refil for whatever chronic pain meds you are on then go wherever the hell you want.
Eydawn Posted November 20, 2013 Posted November 20, 2013 Here's the thing- there's nothing indicating that this child's neurological status is in danger of severe compromise. That's the problem with meningitis. Let's look at this another way- until you really see the hallmark neuro signs, there IS no way to differentiate. And there's no justification for an LP until you have some indicator, right? (Those of you who do LP's, correct me if I'm wrong). I'd say yes, have the kid evaluated if the mom's gut feeling is that something is just plain wonky, but there's nothing here to indicate to a prehospital provider that this kid is in trouble. Hell, that's how many of us get exposed by patients- we have no idea that's the problem until someone comes back with it and then you learn you were exposed... Many people who die of meningitis are asymptomatic or mildly symptomatic until they are massively, life threat level ill. Wendy CO EMT-B RN-ADN
ERDoc Posted November 20, 2013 Posted November 20, 2013 Pretty much what she said. There is nothing here that would make me LP this kid. Are there a few concerning things, sure, especially when we use the retrospectroscope. The photophobia concerns me. The hiding under the blanket could just be because she sees Kiwi entering her room and is scared shitless. Meningitis will present in many different ways, depending on the bug. Pneumococcal meningitis will present with vague symptoms until the pt rapidly deteriorates. Someone once said that if you see the rash it is too late. This is not true but is pretty close.
BEorP Posted November 20, 2013 Posted November 20, 2013 Pretty much what she said. There is nothing here that would make me LP this kid. Are there a few concerning things, sure, especially when we use the retrospectroscope. The photophobia concerns me. The hiding under the blanket could just be because she sees Kiwi entering her room and is scared shitless. Meningitis will present in many different ways, depending on the bug. Pneumococcal meningitis will present with vague symptoms until the pt rapidly deteriorates. Someone once said that if you see the rash it is too late. This is not true but is pretty close. It is good to hear your thoughts on this. So if the patient had been brought to you in ED and presented exactly as Kiwi outlined here, do you think that there would have been any difference in outcome?
ERDoc Posted November 20, 2013 Posted November 20, 2013 Hard to say. I sure would not have jumped on this kid and done the LP. Maybe some blood work and a period of observation to see if something changes.
Kiwiology Posted November 20, 2013 Author Posted November 20, 2013 Here's the thing- there's nothing indicating that this child's neurological status is in danger of severe compromise. That's the problem with meningitis. Let's look at this another way- until you really see the hallmark neuro signs, there IS no way to differentiate. And there's no justification for an LP until you have some indicator, right? (Those of you who do LP's, correct me if I'm wrong). I'd say yes, have the kid evaluated if the mom's gut feeling is that something is just plain wonky, but there's nothing here to indicate to a prehospital provider that this kid is in trouble. Hell, that's how many of us get exposed by patients- we have no idea that's the problem until someone comes back with it and then you learn you were exposed... Many people who die of meningitis are asymptomatic or mildly symptomatic until they are massively, life threat level ill. Whilst you could not realistically be expected to diagnose meningococcal disease in this patient, It is not unreasonable to expect pre-hospital clinical people to make a diagnosis, even if that diagnosis is "I don't know what the hell is wrong", if you are going to treat something you must first of all form a diagnosis but like I said, the diagnosis in this case is less important than recognition that something here is awry. There are a number of signs that something is wrong and that this patient requires further evaluation.
Just Plain Ruff Posted November 20, 2013 Posted November 20, 2013 Ok, let me give you a further challenge. I had two patients. Exact same presentation. I'll give you the LP results massive headache, nuchal rigidity, fever, photophobia, writhing on the bed. These two guys were the same age, same demographics. They both had the same exact history. one came into the ER on a Sunday let's say and the other came in 3 days later. Both attended the same dinner on Saturday night. One presented one day after the dinner the other presented 4 days after the dinner. We LP'd the first guy and yep, his spinal fluid was milky white, he was treated for menigitis and myself and the three other providers were treated for exposure since the spinal fluid was so freaking positive for it. He eventually went on to make a complete recovery. Second guy not so lucky, Our CT scanner was broken. We did an LP on him, now remember, this guy presented with the EXACT same symptoms as MR Meningitis did on Sunday night.. Well his spinal fluid came back bright red blood and actually spurted out of the tube that we put on the LP to check the pressure gradient. He quickly went from writhing on the bed to a quivering mass of a seizing patient who very soon passed away and on autopsy it was found that he herniated his brain due to a major brain bleed. We just hastened his death by allowing the bleed to get worse. Again, exact same symptoms, yet different outcomes. The physician was confident that this was meningitis due to the two men being at the same dinner and being exposed to each other as they were friends.
Just Plain Ruff Posted November 20, 2013 Posted November 20, 2013 damn. You said it sister, I heard that we got our asses sued off but I was never called to court for it. I'm sure the hospital settled as well as the physician did to. That was 20 years ago.
scubanurse Posted November 20, 2013 Posted November 20, 2013 Just goes to show that assumptions about diagnosis isn't going to get you a win.
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