Age: 1.69
Sex: M
Vaccine: MMR, VARCEL, MMR, VARCEL
Symptoms: Cough, Cyanosis, Heart rate irregular, Hyperglycaemia, Hypotonia
Clinical narrative: Information has been received from a physician concerning a 20 month old male with a chronic lung condition (bronchopulmonary dysplasia), severe respiratory distress syndrome, trach in place (due to bronchopulmonary abnormalities), and a medical history of critical care nursing (until 5/11/05), pre-term birth and very low birth weight who on 5/20/05 at 10:00 AM was vaccinated with a first dose of MMR (lot # 649234/0608P). Concomitant therapy included that day and time included a first dose of varicella virus vaccine live (lot # 649271/0652P). Other therapy included Flovent and albuterol. On 5/29/05 the patient was brought to the emergency department at approximately 5:30 AM with fever, cyanosis, low oxygen saturation, and diminished breath sounds. It was the emergency room physician's understanding that the squad had called and they were bagging the child. He had diminished respiratory effort extremely labored, was lethargic, and had no actual movements of any extremities when he arrived in the emergency department. The physician noted that the patient was so hot to touch that it was concerning. The rectal temperature was found to be 107.8 or 107.9 degrees. He had no allergies. There was no other pertinent history. The patient was cyanotic with sats in 60s, respiratory in the high 50s, pulse in the 230s. Initially upon arrival in the emergency department, standard ACLS protocol was initiated. Multiple IV's were attempted and eventually IV was established. The patient was given two 125mcg acetaminophen suppositories. The patient had a small bowel movement and then another one was inserted. The physician placed ibuprofen through the G-tube. Levalbuterol hydrochloride treatment was initiated immediately along with a racemic epinephrine treatment as the patient was having severe respiratory distress. The patient was suctioned multiple times with quite a bit of mucoid looking sputum obtained. A chest x-ray showed some increased interstitial changes on the left versus the right, but the physician could not really appreciated a situation of a volume overload. The patient had diffuse crackles in the bases of his lungs. Upon physical examination, the patient's HEENT examination revealed that eyes were glazed over. He had diminished corneal reflexes. Cardiovascular regular rate and rhythm. S1, 2/6 holosystolic murmur noted. Lungs were coarse rhonchi sounds, extremely diminished, very ronchus as well. The abdomen did not appear distended. He had herniated histoma and the home health nurse thought this was secondary to coughing episode through the night as he had coughed and choked throughout most of the evening according to the home health nurse. The extremities were mottled. He had some delayed capillary refill. The physician could not appreciate any obvious petechia or purpura noted. Neurologically, the child had an altered mental status and certainly diminished GCS. The physician was not certain what his baseline was, but noted it was certainly altered with no evidence of lateralization or obvious focal deficits, but just altered mental status. The patient reported came in extremely septic. Within ten minutes of arrival, the patient had both ceftriaxone sodium and gentamycin given empirically for presumed overwhelming sepsis. The patient had a CBC and chemistry profile drawn. They were unsuccessful in drawing laboratory studies via peripheral access. The physician did a femoral venous puncture and was able to obtain the laboratory studies. Reportedly, a good 30 to 40 minutes into the resuscitation the patient's temperature with fans, cooling blankets, and every maneuver and measure to cool the temperature was down to 103 to 104. The patient was starting to respond. His capillary refill had improved. His pulse was in the 110 to 120 range. His PO2 was in the 92% being assisted with just bag ventilation. The physician did give the patient 120ml per kilo bolus. The physician was concerned that the patient initially presented with congestive heart failure. So a small amount of furosemide sodium was given to ensure continued urine output. The patient did seem to respond very nicely to this and started to perk up and reportedly improved in terms of his initial presentation. The physician contacted another hospital about 30 minutes of the patient's arrival and spoke with the emergency room physician there. The patient had a Pedi bag on, his temperature on disposition was 103.7 degrees, his heart rate was in the 160s. He had good capillary refill on all extremities. He was kicking his legs and remained wakeful. His pulse oxygen was 95%. At the time of disposition at 7:15, his temperature was 102.8 degrees. He had dropped five degrees. Still being intermittently bagged by CPT just to ensure adequate ventilations as the patient's respiratory status laborored and reportedly concerning because of the overwhelming sepsis. His laboratory studies showed sodium 149, potassium 4.6, chloride 100, bicarbonate of 42, albumin of 3.2. His AST and ALT were grossly elevated. His calcium was 7.7, glucose was 344, phosphorus was 4.7, BUN 25, and creatinine of 0.3. WBC was 20.1 which reportedly was to be expected with a significant bandemia and neutrophilia. The physician noted that the patient had overwhelming sepsis that had gone unrecognized for a certain period of time. The physician's impression ws overwhelming sepsis with respiratory distress. Another physician reported that primary cause of patient's cardiac arrest may be related to overwhelming sepsis or related to congestive heart failure. The patient remained asystolic. On arrival at the emergency department, the patient was treated with several rounds of IV epinephrine and atropine as well as atropine and epinephrine given down the patient's tracheostomy. This was combined with chest compressions and appropriate ventilation. The patient failed to respond to this treatment and remained asystolic during his entire emergency department course. The patient was pronounced dead at 8:41 AM. The reporting physician did not feel his illness was due to vaccine. At the time of the report, autopsy report was pending. Additional information has been requested.