Dr. Shashi Ranjani Dr Thangavelu unit Mehta children hospital

Transcription

1 Diagnosis after death Dr. Shashi Ranjani Dr Thangavelu unit Mehta children hospital Management team Dr.V.P.Anitha (consultant PICU) Dr.Mahesh (paediatric neurologist) Dr. Thirumaran (Neurosurgeon) 1

2 4 yr old, girl whose illness was perceived as benign one by the parents Restless throughout the previous night Drowsy from morning Vomiting - 2 episodes treated with antiemetics as OP in the evening Later parents saw her unresponsive, and blue at home rushed to MMM hospital 2

3 Brought in cardiac arrest Resuscitated and ROC appeared after 45 mins CBG 418mg/dl ABG - metabolic acidosis Shifted to mehta with manual ventilation? Cause probable DKA with cerebral edema 3

4 Unresponsive Pupils dilated, not reacting Doll s eye absent Cough / gag reflex absent DTR absent CBG 384mg/dl b/l papilloedema + polyuric 4

5 DKA with cerebral edema Intracranial pathology (tumor/bleed/avm) Unwitnessed seizures Poisoning Envenomation 5

6 Day 1 Day 2 Hb(g%) TC(cells/cumm) DC P78 P64 Plts(lakhs) Na(meq/L) HCO SGOT SGPT

7 Serum osmolality 353osm/L Urine osmolality 120osm/L Urine Na 39meq/L Urine ketones negative HbA1C 5.2 % Amylase 566 U/L Lipase 49 U/L Lactate 6.1 mg/dl Ammonia 315 mcg/dl 7

8 ECHO 40%EF Parents were councelled that further investigation may not help the child but is necessary for diagnosis 8

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11 MRI mass in cerebellar vermis compressing the brain stem causing hydrocephalus - tonsillar herniation 2 cm below the foramen magnum? Juvenile pilocytic astrocytoma 11

12 Ventilated Insulin infusion, Ionotrops adrenaline, dobutamine and vasopressin As child did not have any brain stem signs parents counseled and treatment not escalated Child died after 48 hrs. 12

13 No polyuria or polydipsia Child slept for >12 hrs in the night without voiding urine. No history suggestive of poisoning/ envenomation 13

14 Supratentorial 1. Uncal 2. Transtentorial (central) 3. Cingulate(subfalcine) 4. Transcalvarial Infratentorial 5. Upward (cerebellar/ transtentorial) 6. Tonsillar (downward cerebellar) 14

15 1. Intracranial pathology (Trauma, hemorrhage, tumor with herniation) 2. Unwitnessed seizures 3. Poisoning 4. Unidentified injury 5. Envenomation 15

16 Stress diabetes or diabetes of injury Range mg/dl (can exceed 500 mg/dl) Returns to normal within hours Hypertonic dehydration and with elevated catecholamines counter regulatory hormone and cytokine responses of critical illness 16

17 Stress hyperglycemia DKA No polyuria Polyuria + Urinary ketonesneg Urinary ketones+ HbA1C normal Increased Insulin sometimes Insulin always 17

18 cystic cerebellar astrocytoma (WHO grade I) benign tumor Peak age at 5-9 years. cerebellum, near the brainstem, hypothalamic region, or the optic chiasm, cerebral hemispheres and the spinal cord 18

19 Failure to thrive Headache, nausea, vomiting Irritability Incoordination Visual complaints 19

20 Macroscopically - well-circumscribed mass has a large cyst Microscopically - composed of bipolar cells with long "hairlike processes, rosenthal fibres, eosinophilic granular bodies and microcysts. giving the designation "pilocytic. 20

21 Pilomyxoid astrocytoma (PMA) is a variant of pediatric astrocytoma. Have different histologic features Behave more aggressively than pilocytic astrocytomas. 21

22 Surgery is often the treatment of choice. Total resection is often possible; The five-year survival has been reported to be over 90% After total resection the 10-year survival rate is 90%. After incomplete resection, the 10-year survival rate is 45% 22

23 Do we need Dx after death? 23

24 Medical and legal issues arising out of it Death certification should need a reasonable correct diagnosis Parents question, why? What? Has it been answered with reasonable accuracy. If we cannot reach a dx, significant causes should be excluded 24

25 Should we register as MLC? Cause of death in the death certificate? In a girl child abuse has to be ruled out Negative examination findings to exclude abuse Who will pay the bills? Why? 25