Toddler Dies Following Physician’s Failure to Diagnose Tonsillar Herniation

Case Summary

A previously healthy male toddler presented to the Emergency Department complaining of vomiting and diarrhea for 24 hours. Prior to presenting to the ER, the child had been awake for only one hour in the past 36 hours.

The child appeared to be ill upon examination. Laboratory results revealed slightly low chloride levels of 98, sodium levels of 130, bicarbonate levels of 17.3, and glucose levels of 45. The treatment team attempted IV placement several times, but eventually, the team gave up. The hospital discharged the child after giving him ibuprofen and ondansetron.

The following day, the child returned to the ER. According to the mother, the patient had lost two pounds since his symptoms began. At this visit, the labs revealed significant derangements, including an arterial pH of 6.79, potassium of 2.5, renal failure, and glucose of over 500. An episode of coffee ground emesis, unresponsiveness, and arrest occurred shortly after the infant arrived in the emergency room. The patient was intubated and transferred to an outside hospital. Shortly following the transfer, imaging revealed that the child had diffuse cerebral edema with tonsillar herniation. After a short course of treatment, care was withdrawn and the child died.

Case Theory

Tonsillar herniation occurs when brain tissue moves from one intracranial compartment to another, specifically when the cerebellar tonsils move through the foramen magnum. It is a time-critical, life-threatening condition that may be reversible with emergency surgical intervention and medical treatment. Swelling in the infratentorial space (such as cerebral hemorrhage) usually causes a tonsillar herniation. As the cerebellar tonsils pass through the foramen magnum, they compress the brain stem and obstruct the flow of cerebrospinal fluid (CSF). The condition is often described as “coning” as brain tissue is squeezed down through the foramen like being squeezed into a cone.

In CT and MRI scans, tonsillar herniation can be seen as effacement of the CSF cisterns around the brainstem and as inferior descent of the cerebellar tonsils. The mainstay treatment of meningoencephalitis is intravenous antimicrobial therapy. In cases of diagnosed tonsillar herniation with reactive pupils and rapid access to the neurosurgical unit, surgical intervention can be lifesaving to restore the craniocervical junction CSF flow.

The child’s medical care during the first visit to the Emergency Department was negligent and violated the standard of care. The hospital should not have discharged the child. His abnormal lab results and symptoms required further investigation and treatment.

Expert Witness Specialities

Pediatric Emergency Medicine

Pediatric emergency room doctors can speak to diagnostic medicine standards for sick children with similar blood values and symptoms. This expert can opine on the quality of care delivered in this case.

Questions for Expert Witnesses

• When a similar patient presents with somnolence, vomiting, diarrhea, hypoglycemia, and acidosis, what should be done for work-up and potential treatment?
• What is the standard of care for suspected tonsillar herniation?
• What is the patient prognosis with and without emergent care for tonsillar herniation?
• Was the discharge of this patient negligent?

Expert Witness Involvement

Here is what the pediatric emergency physician in this case had to say:

Expert Witness Response E-007475

I am a board-certified pediatric emergency physician. I exclusively care for children in the emergency department setting. I have seen multiple patients who present ill-appearing and with metabolic abnormalities including hypoglycemia and acidosis. When a patient presents with some somnolence, vomiting, diarrhea, hypoglycemia, etc., the patient should be given a fluid replacement. This can be done either intravenously or nasogastrically as a temporary measure.