The case involves a five year old child who developed flu-like symptoms. He presented to the hospital with fever, dehydration, and lethargy. The child’s parents were originally concerned with the frequency of the child’s vomiting so they brought the child be seen in the ED. After a short hospital stay the patient was diagnosed with a viral illness and sent home with supportive care. However, due to continued vomiting the child’s parents took the patient back to the ED the next day, however she was discharged a second time shortly after arrival. The child was brought to the ER a third time, where he was tachycardic and hypoxic. The patient was transferred to PICU where the patient eventually expired. Blood cultures obtained prior to initiation of antibiotics were positive for a bacterial infection that went undiagnosed during his hospital stay.
Question(s) For Expert Witness
- 1. How often do you care for infants with cold/flu-like symptoms in the ED?
- 2. How can one distinguish between self-limiting, viral illness and bacterial illness which needs elevated care?
Expert Witness Response E-073528
The management of an infant with cold and flu-like symptoms is very common and I frequently see children in that age group in our Pediatric ED. It is one of the most frequent chief complaints. Vital signs are often helpful. Very high fever 40 F +, low BP, high HR, refusal to eat, sickly appearance including listlessness are initial criteria. Lab tests including WBC poor prognosticator, CRP, which is better or Procalcitonin helps. A UA is mandatory but needs to be a cath specimen. A very ill appearing child needs an LP. Flu test are unreliable unless they are PCR respiratory panels. Again, abnormal vital signs such as a high HR or a low pulse oximeter requiring oxygen are a good starting point, poor feeding, irritability are indications to admit a patient. Abnormal inflammatory markers are another criteria. The need for IV antibiotics in a sick appearing child. However, there is not one perfect test apart from a positive lumbar puncture or a positive chest X-ray that shows a large lobar or multifocal pneumonia.
Expert Witness Response E-059894
I often care for patients with symptoms similar to what is described for this patient. While most infections in infants are self-limited viral infections, rarely a more serious bacterial infection leading to sepsis will be the cause. Differentiating signs on the physical exam include the infant’s heart rate, overall appearance, and activity level. The definitive test for bacterial infection of the blood is a blood culture, though the results are not immediately available and so the clinician has to decide based on the signs described whether to treat for presumptive bacterial infection, recognizing the overall rarity of such an infection. Indications for ED referral and then hospitalization include, most importantly, the infant’s clinical signs on physical exam, as well as the progression of symptoms. Patients with elevated heart rate, who look ill, and who have other potential signs of bacterial infection require more aggressive treatment and hospitalization.