This case involves a two-month-old female who was admitted to the hospital for intractable vomiting after feedings. Blood work was sent but showed a normal WBC count and the patient was discharged when she began to clinically improve. The patient’s health declined rapidly at home and when she was brought to the pediatrician’s office the baby became unresponsive. She was rushed back to the emergency room and CPR was initiated during transport. The patient was diagnosed with anoxic brain damage and blood cultures taken were now positive for Group B Strep. Her condition progressed to GBS bacteremia, presumed meningitis, respiratory failure, progressive encephalomalacia with associated ischemic changes. The patient presently is at home under a home care nursing service in a neurologically compromised state.
Question(s) For Expert Witness
- 1. What is the proper emergency department work-up for a patient like this?
Expert Witness Response E-000320
When a two-month-old child presents to the ED with fever and is hypoxic, an aggressive work-up is warranted. This would include a complete blood count, comprehensive metabolic panel, blood culture x 1, urinalysis and urine culture, chest x-ray and a lumbar puncture. Prior to the lumbar puncture, an IV should be started and the child should be started on a bolus of normal saline, 20 mg/kg, followed by maintenance IV fluids. Immediately upon completion of the LP, IV antibiotics should be given with a view towards treating acute bacterial meningitis. Regardless of the labs, the child should ultimately be admitted. It was far below an accepted standard of care to not initiate IV antibiotic therapy in the ED in this child with a fever, elevated bands on the CBC and possible pneumonia with hypoxemia. Why this child did not receive IV antibiotics in the ED is a mystery to me.