6/11/21 at 10:30pm, 3 y/o female admitted to a children's hospital Michigan following MVA. Monitored in hospital and due to increasing pain, decision made to go to OR on 6/13/21 at 8:27am. (34 hours post admission). Intraoperatively, found large amount of fluid and fibrinous exudate. 2 areas of mesenteric tear and perforation found and repaired in mid small bowel area.
Surgery end 11:13am.
At 12:46pm HR 169; RR 33; BP 77/52.
4:00pm, HR 175;RR 54; BP 105/62.
6:00pm, HR 150's-170's; SBP 100's/60's; RR 40-50.
8:00pm, HR 182; RR60.
12:35am on 6/14/21, CXR lung volumes low with diffuse hazy opacities bilaterally that are new.
7:00am fever at 101.5.
8:00am temp 104.
8:30am began to desaturate.
9:27am DX was compensated shock. Decision made to intubate and during attempt, massive aspiration resulting in code blue and 90 min downtime.Patient never regained consciousness. Child was never stabilized and continued to deteriorate and coded multiple times and died on 7/1/21.
Autopsy identified atlanto-occipital dislocation but no symptoms of any kind on x-ray or clinically suggestive of a problem prior to aspiration.
Looking for expert to review and address AOD and if it played any role in death.
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Do you believe there might have been medical error?
Difficult to determine the ideology of the injury without reviewing the initial images. Concerning that the patient had increasing pain
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Motor vehicle crashes typically have high impact and at this age group no more likely location of injury is in the upper cervical spine.
What makes you a good expert for this case?
Area of expertise includes cervical spine pathology.
How often do you encounter cases similar to this one in your practice?
at least once a month. encounter cases similar to this one.
Do you believe there might have been medical error?
Inadequate information is given in the summary. There is a clear protocol for clearance of the cervical spine in the pediatric trauma patient. https://publications.aap.org/pediatrics/article/144/2_MeetingAbstract/732/3838/Pediatric-Cervical-Spine-Clearance-A-Consensus?autologincheck=redirected The described occurrence could certainly be from spinal shock due to undiagnosed cervical spine injury. The need for pediatric cervical spine clearance is seen several times a day in most Level I trauma centers(we certainly perform it frequently). You need someone to confirm there was appropriate clearance of the cervical spine. If so, this is an unfortunate error(one I have never seen in >30 years of pediatric neurosurgical experience). If there was a failure to appropriately clear the cervical spine, there is a real issue. Note that this is under neurosurgery. There is a separate(dependent) board for pediatric neurosurgery. You want a board certified pediatric neurosurgeon for this case. A listing can be found at www.abpns.org
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. If there was a failure to clear the cervical spine, there is clear causation. If this is an unfortunate sequence, one could make the argument that the trauma of the code itself led to the AOD.
What makes you a good expert for this case?
Double board certified(adult and pediatric) neurosurgeon, currently working in Level I trauma center, who has published chapters on the management of pediatric neurotrauma, and case reports on AOD, specifically. Pediatric neurosurgery is a small community. Most of us will not serve as an expert against another pediatric neurosurgeon(as I would not). If there is a pediatric neurosurgeon named in this case, I would need the name but would most likely be conflicted out.
How often do you encounter cases similar to this one in your practice?
Similar cases as in pediatric trauma requiring clearance of the cervical spine, daily(and have been practicing 30 years). Similar as in AOD causing death, only in the immediate trauma setting(coding as they arrive, etc). Most cases of AOD die in the field. The above case would be very rare(I have never had a child die from possible spinal shock, with an autopsy diagnosis of AOD, not diagnosed while they were alive). Were there any other diagnoses that could cause ligamentous laxity, e.g. Down's syndrome, EDS, etc? Those could also muddy the waters.
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