A 2-year-old girl is brought to the clinic due to vomiting. Vomiting has occurred every morning for the past week but has increased in frequency and now occurs intermittently throughout the day. Today, the patient has vomited 8 times and become irritable and lethargic but has had no hematemesis, diarrhea, or sick contacts. She was born at 29 weeks gestation and has a ventriculoperitoneal shunt that was placed after birth due to intraventricular hemorrhage. Temperature is 36.7 C (98.1 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 24/min. Physical examination reveals a sleepy, irritable child. The anterior fontanelle is enlarged and tense. Pupils are equal and reactive, and funduscopic examination is limited by lack of patient cooperation. The abdomen is soft and mildly tender to palpation. There is no rebound, guarding, or palpable mass. Skin turgor is decreased, and capillary refill is 2 seconds. Which of the following is the best next step in management of this patient?

Question

A 2-year-old girl is brought to the clinic due to vomiting.  Vomiting has occurred every morning for the past week but has increased in frequency and now occurs intermittently throughout the day.  Today, the patient has vomited 8 times and become irritable and lethargic but has had no hematemesis, diarrhea, or sick contacts.  She was born at 29 weeks gestation and has a ventriculoperitoneal shunt that was placed after birth due to intraventricular hemorrhage.  Temperature is 36.7 C (98.1 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 24/min.  Physical examination reveals a sleepy, irritable child.  The anterior fontanelle is enlarged and tense.  Pupils are equal and reactive, and funduscopic examination is limited by lack of patient cooperation.  The abdomen is soft and mildly tender to palpation.  There is no rebound, guarding, or palpable mass.  Skin turgor is decreased, and capillary refill is 2 seconds.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6ef_f654_bc81_e989b124a7bc_MD0003_00 This child has signs of increased intracranial pressure (ICP), a life-threatening condition in which the brain parenchyma, cerebrospinal fluid (CSF), or cerebral blood flow increases in volume. Without prompt treatment, elevated pressure within the cranial vault can lead to brain herniation, ischemia, and death. Severe headache, particularly causing nighttime awakening, is often the earliest manifestation of increased ICP. However, young children unable to verbalize headache are more likely to be irritable with intractable vomiting and lethargy, as seen in this patient. A bulging anterior fontanelle may be present in an infant (prior to fontanelle closure at age 9-18 months) or in a child with a persistent open fontanelle due to chronic hydrocephalus, as in this patient. Papilledema (ie, optic disc swelling) is more common in older children with fused sutures. This patient has a ventriculoperitoneal (VP) shunt, which is placed as a long-term solution for draining excess CSF into the abdomen of some patients with persistent ventricular dilation following intraventricular hemorrhage. A VP shunt increases the risk for elevated ICP due to shunt malfunction (eg, catheter obstruction, shunt migration, split tubing). Urgent brain imaging with CT scan or fast MRI is required to evaluate for ventriculomegaly, mass effect, and impending herniation. Shunt series radiographs are also typically performed to identify displaced/damaged tubing. Confirmed shunt malfunction warrants surgical shunt revision. ventriculoperitoneal (VP) shunt (Choice A) Abdominal ultrasound may be performed to identify a pseudocyst (ie, CSF-filled mass), which can present with abdominal pain and increased ICP. The pseudocyst can also cause abdominal distension and a palpable mass, findings not seen in this patient. (Choice C) Regurgitation can occur with gastroesophageal reflux, but frequent emesis is not typical. Therefore, proton pump therapy for reflux would not be beneficial in this patient with intractable vomiting. (Choice D) Although therapeutic lumbar puncture may help relieve ICP in a patient with communicating hydrocephalus, imaging should be performed first to evaluate shunt function and identify the etiology of increased ICP. (Choice E) Supportive care and observation are appropriate for viral gastroenteritis in a previously healthy, well-hydrated patient. However, this patient with a VP shunt has findings of increased ICP that warrant neuroimaging. Educational objective: Signs of increased intracranial pressure in young children include irritability, intractable vomiting, lethargy, and a bulging fontanelle. Urgent brain imaging is necessary to evaluate for ventriculomegaly, mass effect, and impending herniation. References: Rate and risk factors for shunt revision in pediatric patients with hydrocephalus-a population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/28213196)

A 2-Year-Old Girl Is Brought to the Clinic Due to Vomiting