FAILURE TO DX APPENDICITIS IN A 2 YO

11/14 brought to ped. Fever, vomiting, lethargy. No Physical exam noted. BP, HR, RR, pulse oximetry all unchecked. Fever 103. Only diagnosis made was viral gastroenteritis and pt was sent home. No differential was made. 11/15 parents called ped for persistent high fever. Ped said watch the fever and manage it with tylenol. Did not request to see the boy. 11/16 pt back to ped for high fever, lethargy, excessive crying and crankiness. Thought it to be viral syndrome and sent him to ER NO Phys exam, BP, HR, nor pulse oximetry were taken nor diagnosis reached. Child goes home and then to the ER. Fever, grasping penis, cranky, non stop crying. WBC 31,000 with shift to the left. Breathing was shallow and fast. No bp check. HR 168. NO RR check. No pulse oximetry. Failure to check capillary refill for hypoperfusion. Diagnosed with unstaged sepsis. Gave the boy a shot of rocephin and spoke with ped who said release the boy and told parents to bring him in to peds on 11/17. Ped measured temp at 104.2 He was noted to be awake, alert and crying. Ped knew WBC of 31,000. Abdomen noted soft, NT, ND. parents stated he could not crawl or walk and would fall when he was stood up. Impression was bacterimia – nothing else and sent child home with antibiotic. 11/18 appendix burst necessitating 2 1/2 mos in hospital. Has trouble eliminating bowels to this day.

1. Did ER depart by agreeing with ped who said release child even though wbc of 31,000 and a diagnosis of sepsis.

2. Should appendicitis be on the radar? even as a 4th possibility after say pneumonia and meningitis?

3. Wouldn’t an abdominal x-ray or ultrasound diagnosed the appendicitis and shouldn’t at least one been ordered?

EXPERT RESPONSES

The pediatrician breached std of care as did the ED physician. The ED physician should never have diagnosed a pt of this age with sepsis or bacteremia and sent the child HOME. As for diagnosing the appendicitis, it is very tricky in this age group, but physical exam of the abdomen may have clued the ED docs into need for either ultrasound (preferred) or CT scan. An x-ray is almost never helpful in diagnosing appendicitis, unless there is a huge rupture, and then you will see a non-specific finding of free air, but you still do not know WHAT has ruptured. In fact, a regular chest x-ray should show free air under the diaphragm, if it is present. Certainly a septic kid with a wbc =31K should prompt consideration of intra-abdominal pathology if chest xray is negative for pna, and urinalysis unrevealing for urosepsis. There were so many breaches in the standard of care….. Dr KJ – ER

2 yo children with sepsis should not be treated with a single dose of antibiiotics and sent home. The WBC of 31,000 is not the issue in this question, but more how to manage that diagnosis. I don’t understand the pediatrician managing the child over the phone and not seeing the kid. The ER was not wrong in over ruling if they agreed.It is inconsistent to diagnose sepsis and send the child home. WBC of 31,000 does not mean sepsis.AP is a tough diagnosis, especially in preschool children who almost always present perforate. The WBC of 31,000 indicates that the child was perforated at that time already. An US might have made the diagnosis depending on the abilty to get one. Alternatively, a CT could have been done. Either would have required an index of suspicion. Without an exam it is impossible to guess if appendicitis should have been suspected. A KUB, or abdominal xray probably would not have helped, which is why US or CT are preferred. Dr JB – Ped

Looks like there were numerous oversights in this case. This child should have had blood work and admission to the hospital early in the course. That being said, appendicitis is very hard to diagnose in a baby. But careful physical examinations and seeing how the baby responded to inpatient therapy should have alerted the doctors that something was going on in the belly. Dr SS – Ped