Discussion Board

 View Only
Expand all | Collapse all

Baby diagnosed with a sprain had actually suffered a stroke

  • 1.  Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-26-2021 22:26

    Baby diagnosed with a sprain had actually suffered a stroke



  • 2.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 12:37
    I have heard of too many pediatric misdiagnoses that appear to be related to a reluctance to do CT scans on children. The protocols seem to override all common sense. Is there a good way to address this?





  • 3.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 14:42
    As a group: please answer the following question:
    What is the frequency of the sought after pathology, expressed per 10,000 population?
    Tom Benzoni





  • 4.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 15:32
    Exactly, why we have to wait for AI where frequencies will be important.  And one could expect frequencies for different parts of the country and screening questions for foreign travel. 

    All the discussions about diagnosis are irrelevant without frequency considerations.

    Trust your Thanksgiving went well. Did you have to work? Can you handle another massive episode of an alternative strain of Covid. 

    The AF arrhythmia is a little better. Heart seems regular, diarrhea has gone after getting rid of some of the meds. Interestingly, all recommended by the nurse practitioner who was new from the Cleveland Clinic having worked for a cardiac electrophysiologist.

    Had a funny thing happen here two nights ago. 

    A visitor from another Arizona city to a family across from us left her car in the road next door to us.for the night, Unbeknown to us it was jacked up on bricks during the night and an air filtration unit removed and stolen. Apparently that unit had expensive metals in it that could be sold too others for good money..Had not herd of that before.

    Stay Well,

    Rob









  • 5.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 15:36

    I believe the pathology in this case was lenticulostriate vasculopathy – not uncommon. According to one report, the incidence varies from 0.3% to 32% depending on the population studied. It suggests some prior insult to the brain. A variety of associations with other conditions, both infectious (CMV) and others have been suggested.  The condition may make the blood vessels that supply this area of the brain more rigid and vulnerable to stretching injury compared with normal vessels. So, relatively mild trauma may cause injury to the arteries (vasospasm or clot formation) that may have led to a stroke. Apparently, the initiating event was the child having a 'mild' fall backwards bumping its head.




    ------------------------------
    Pat Croskerry
    Dalhousie University
    ------------------------------



  • 6.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 15:40
    And what do we do about it?






  • 7.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 18:16

    To Helen's initial observation, there is certainly a reluctance to perform CT on young children...the highest risk for subsequent head and neck cancers following ionizing radiation exposure is in children < 1 y/o. Indeed, I have to have repeated conversations with residents in my pediatric ER about balancing risks and benefits of CT for evaluating for very real life-threatening conditions versus unnecessary imaging. However, there are some important considerations beyond that contribute to the decision to obtain axial neuro-imaging in young children.

     

    1. The technology of the scanner: not all CT scanners are created equal and not all centers adjust radiation dose based on patient size. A CT scan at my quaternary pediatric center is much more likely than a community hospital or critical access hospital to have radiation dose adjustments for size
    2. The experience of the staff: before working in a level 1 pediatric trauma center, I worked in a community ED. The techs would not perform CTs in kids under about 4 without sedation because they had little experience and, therefore, competence at calming a scared child enough to be still for a 30 second study. I have maybe had to sedate 2-3 kids in 15 years at CHCO.
    3. MRI is not quick, often requires sedation in this age: however, fast MR sequences that can identify a significant amount of pathology are being used more commonly in young kids without the need for sedation. (Lindberg DM,et al. Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children. Pediatrics. 2019;144(4):e20190419PMID: 31533974.)
    4. The incidence of ischemic stroke outside the neonatal period: kids under 10 probably have an incidence of CVA around 1-3/100,000 (compared to 32/100,000 in adults 45-49; UpToDate). Thus the pretest probability for CVA in an 11 month old infant such as in this story has significant implications when considering factors #1 and #2 above.
    5. As Dr. Croskerry pointed out, this child had a condition called lenticulostriate vasculopathy (LSV), which has mostly been studied in the neonatal age range, particularly among premature infants. Having been a pediatrician/pediatric ED doc for nigh on 20 years, this is the first I've heard of the condition. It's quite challenging to look for something one doesn't know exists.

     

    In general, this child's experience, while certainly influenced by a general reluctance to expose infants and young children to ionizing radiation, has a lot more to do with how health care (and research including dx error research) for children is prioritized, funded and taught. In the US, Emergency Medicine residency requires that only 20% of patients are pediatric. General EM physicians are excellent at managing pediatric trauma, minor illness, and resuscitations in otherwise healthy kids presenting with life-threatening conditions that are clear cut (sepsis, cardiac and pulmonary arrests, DKA, seizures). But identifying focal neurologic deficits in a child just learning to crawl is an immense challenge; more so when you're not as comfortable with fussy infants and toddlers with stranger anxiety. Indeed, even when seen at Sick Kids in Toronto, the diagnosis was missed. Was this due to time pressures, the experience of the examiner, the patience of the examiner, the thoroughness of the neurologic exam, cognitive biases? Probably a combination of several, I would suspect.

     

    We (health care professionals  and lay society) have put a lot of faith in technology to reduce these errors – perhaps we think it is cheaper and more reliable. But, I would posit the solution lies partly in teaching better physical exam skills, history taking skills (i.e., listening) and critical thinking skills and promoting improvements that allow clinicians time to examine and think about their patients.

     

     

     

    jg

     

    Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics 

    Section of Emergency Medicine | University of Colorado

    Medical Director – Diagnostic Safety Program

    Children's Hospital Colorado

    joe.grubenhoff@childrenscolorado.org

    signature_829143088

    This is Quality Management information relating to the evaluation or improvement of health care services, and is part of a Quality Management program as described in 42 U.S.C.A 299, et seq., 42 C.F.R. 3.206 et seq., C.R.S. § 25-3-109 et seq., and C.R.S. § 12-30-204 et seq.. It is confidential and protected under C.R.S. § 12-30-204 et seq., C.R.S. § 25-3-109 et seq., 42 U.S.C.A. 299, et seq., and 42 C.F.R. 3.206 et seq., and is to be used for Children's Hospital Colorado purposes only. It is confidential, privileged and protected under the same references.

     






  • 8.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-27-2021 19:17
    Thanks Dr. Gubenhoff,

    While waiting for Artificial Intelligence to leld the way would it be good to work on the common "tests" that we do to create greater accuracy and value in the diagnostic process?

    And then what tests would it be good to work on right now to demonstrate we are doing something positive.

    This is a good discussion- let's make it more valuable

    Robert Bell, M.D..








  • 9.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-28-2021 07:39
    Thank you to Dr. Grubenhoff for his well outlined explanation. I would add as a pediatric radiologist that there has been a long collaboration called Image Gently (imagegently.org) to advocate and educate all stakeholders about when and how to image children for these very situations. We created a module called 'Think-A-Head' and I attach one of the articles along with one with the evidence of CT dose variation-- which is, as expected, lowest in children's hospitals.
    In addition to commitment to education throughout our careers (being curious and humble), an important solution is clinical decision support at order entry that provides the evidence for or against using health care resources. The real question we face is not IF we can do a procedure but WHETHER we should do so.
    One other note about lenticulostriate vasculopathy in the infant. While it may be rare in one medical specialty knowledge base, it was something I saw almost daily in the practice of cranial ultrasound, especially in premature infants. It is more often considered a normal variant than a cause of anything. There are several associations with this incidental finding that include TORCH and cocaine abuse in the mother.

    Kimberly Applegate, MD, MS
    Retired Professor of Radiology and Pediatrics,
    University of Kentucky College of Medicine

    Founding Member, Steering Committee of Image Gently Alliance





    Attachment(s)



  • 10.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-28-2021 10:50
    I think this may be an example of a classic cognitive error.
    Who in this group can identify it?
    (I'll give you a hint; Kahneman, "Noise", which I'm certain all of you have read.)

    tom benzoni

    PS: Stay tuned: I'll give you a chance at redemption. Coming in 3 minutes.





  • 11.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-28-2021 11:02
    Ok, here's your chance:
    For a $25 Caribou gift card (for real; this is the card number: 6000148400014900889. I will send the PIN to the winner. I'm serious.)

    I'm at work in the ER this Sunday morning. (Where is important only if you can tell why.)
    Case: Young adolescent is here in room 13. They complain of pin/pain feelings.
    Present 7 - 10 days.
    PM/SH (-)
    Rx: none
    F/SHx: 8th grade
    PE: VS nl.

    What would you like to know? You have 1 hour. The window closes then.

    PS: This is a real patient I am now assessing. I've changed enough to be HIPAA-ok without changing the info you need.

    Go.

    tom benzoni





  • 12.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-28-2021 13:00

    Region of US for risk of tick borne illness?

    Associated symptoms?

    Where are the pin/pain feelings located?

     

     






  • 13.  RE: Baby diagnosed with a sprain had actually suffered a stroke

    Posted 11-28-2021 19:07
    Tom,

    Will you tell us what diagnosis you made? The window has closed.

    Terry Graedon (no clinician, so not part of the competition)