A 2-year-old boy is brought to the emergency department by his grandmother due to abdominal pain and lethargy. The grandmother reports that he was playing calmly last night when he suddenly began screaming and holding his abdomen. The pain resolved after several minutes, but the patient has had 5 additional episodes of sudden-onset, severe pain since then. Today, the grandmother notes that he has no interest in eating or drinking and has been "sleeping all day" but intermittently awakens in pain. The patient has also had several episodes of nonbloody, nonbilious emesis and "fewer wet diapers than usual." He has had no fever, diarrhea, or recent infections. He is an otherwise healthy child with no prior hospitalizations or chronic medical conditions. The patient takes no medications, and his immunizations are up to date. Temperature is 37 C (98.6 F), blood pressure is 90/56 mm Hg, pulse is 160/min, and respirations are 24/min. During the examination, the boy is sleeping and arouses briefly. The abdomen has hypoactive bowel sounds and diffuse mild tenderness to palpation. He is circumcised, with both testes descended and with intact cremasteric reflexes. Immediately after the examination, the child passes blood in his diaper, as shown in the image below. The medical team has determined the appropriate procedure. The patient lives with his parents and his grandmother about an hour away from the hospital. His grandmother drove him to the emergency department but is not his legal guardian. She states, "His mom should be on the way; she probably just left the house." However, despite multiple attempts, the medical team is unable to reach either of the patient's parents by telephone. Which of the following is the most appropriate next step in management of this patient?

Question

A 2-year-old boy is brought to the emergency department by his grandmother due to abdominal pain and lethargy.  The grandmother reports that he was playing calmly last night when he suddenly began screaming and holding his abdomen.  The pain resolved after several minutes, but the patient has had 5 additional episodes of sudden-onset, severe pain since then.  Today, the grandmother notes that he has no interest in eating or drinking and has been "sleeping all day" but intermittently awakens in pain.  The patient has also had several episodes of nonbloody, nonbilious emesis and "fewer wet diapers than usual."  He has had no fever, diarrhea, or recent infections.  He is an otherwise healthy child with no prior hospitalizations or chronic medical conditions.  The patient takes no medications, and his immunizations are up to date.  Temperature is 37 C (98.6 F), blood pressure is 90/56 mm Hg, pulse is 160/min, and respirations are 24/min.  During the examination, the boy is sleeping and arouses briefly.  The abdomen has hypoactive bowel sounds and diffuse mild tenderness to palpation.  He is circumcised, with both testes descended and with intact cremasteric reflexes.  Immediately after the examination, the child passes blood in his diaper, as shown in the image below.  The medical team has determined the appropriate procedure.  The patient lives with his parents and his grandmother about an hour away from the hospital.  His grandmother drove him to the emergency department but is not his legal guardian.  She states, "His mom should be on the way; she probably just left the house."  However, despite multiple attempts, the medical team is unable to reach either of the patient's parents by telephone.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf1f_b76e_8f63_63dff2648cd7_MD0005_00 This child has intussusception, a medical condition that requires immediate diagnostic and therapeutic care. Informed consent is typically obtained prior to any significant procedure (eg, air enema) to ensure that the patient is a knowledgeable participant in the health care decision and is aware of the nature, alternatives, risks, and benefits of the procedure. For patients who are minors, informed consent must be provided by a legal guardian (a parent in most cases); there should always be multiple attempts to contact the legal guardian(s). An exception is emergency care, in which delaying treatment could lead to harm. Other exceptions for minors include treatment of sexually transmitted diseases, contraception, and in most states, provision of substance use disorder treatment and prenatal care. (Choices A and B) If the nature of this patient's diagnosis and treatment did not require emergency care (eg, antibiotics for otitis media, streptococcal pharyngitis), any procedures or care that require consent should be delayed until consent can be obtained from the legal guardian. In general, consent from one legal guardian is sufficient to proceed with medical care. (Choice C) This patient's grandmother cannot provide consent as she is not the legal guardian. (Choice D) This patient cannot provide consent due to his young age. Minors may become emancipated and consent for their own medical care if they are homeless, married, a parent, in the military, financially independent, or a high school graduate. Educational objective: Emergency diagnostic or therapeutic care can be provided to minors without consent if their life or health is at imminent risk and the legal guardian is unavailable or unable to provide consent. References: Consent for emergency medical services for children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/21788221)

A 2-Year-Old Boy Is Brought to the Emergency Department by His