What is the appropriate management for a toddler presenting with abdominal distension and blister-like lesions all over the body?

Management of Toddler with Distended Abdomen and Blister-Like Lesions

This toddler requires immediate multidisciplinary evaluation for a potentially life-threatening condition, with urgent dermatology consultation for suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) and simultaneous assessment for complicated intra-abdominal pathology.

Immediate Stabilization and Assessment

Airway and Breathing

• Assess airway patency immediately by a pediatric anesthetist or intensivist, especially if mucosal involvement is present, as SJS/TEN can cause airway compromise requiring intubation 1
• Ensure immediate availability of appropriate equipment for difficult intubation if oral/pharyngeal lesions are present 1
• Measure oxygen saturation with pulse oximetry and provide supplemental oxygen if needed 1

Circulation and Fluid Resuscitation

• Establish peripheral venous access through non-lesional skin if possible and commence appropriate intravenous fluid resuscitation 1
• For shock or severe dehydration, administer normal saline 20 ml/kg bolus rapidly 2
• Accurately record fluid intake, output, and balance 1

Vital Signs and Physical Examination

• Record baseline body weight, vital signs, and temperature 1
• Examine skin systematically: document extent of erythema and epidermal detachment separately on a body map, estimating percentage of body surface area involved 1
• Look specifically for target lesions (particularly atypical targets), purpuric macules, blisters, and areas of epidermal detachment 1
• Examine mouth, eyes, and genitalia (including perianal skin) for mucositis, blisters, and erosions 1

Abdominal Assessment

• Perform focused abdominal examination looking for distention, tenderness, guarding, rebound, bowel sounds, and masses 2
• Assess for signs of peritonitis, bowel obstruction, or perforation 1
• Consider referred abdominal pain from pneumonia by examining respiratory system 2

Urgent Investigations

Dermatologic Workup

• Skin biopsy from lesional skin (just adjacent to a blister) for routine histopathology 1
• Second biopsy from perilesional skin sent unfixed for direct immunofluorescence to exclude immunobullous disorders 1
• Photographs of skin showing type and extent of lesions 1
• Bacterial swabs from lesional skin for culture and sensitivity 1
• Conjunctival swabs for bacteria, chlamydia, HSV (PCR), and adenovirus (PCR) 1

Laboratory Studies

• Full blood count, C-reactive protein, urea and electrolytes, liver function tests, coagulation studies 1
• Glucose, magnesium, phosphate, bicarbonate, base excess, lactate 1
• Infection screening including mycoplasma and chlamydia serology, skin swabs for HSV and varicella zoster virus 1
• Blood, stool, and urine cultures if sepsis suspected 3

Imaging

• Ultrasound abdomen as first-line investigation for moderate-severe abdominal pain with localizing findings 2
• Chest X-ray to exclude pneumonia as cause of referred abdominal pain 1, 2
• Consider contrast-enhanced CT abdomen if significant trauma, pancreatitis, or surgical abdomen suspected 2

Specific Management Considerations

For SJS/TEN

• Within 24 hours of diagnosis, arrange ophthalmology examination by specialist experienced in ocular surface diseases in children 1
• Convene multidisciplinary team including dermatology/burns specialist, pediatric intensive care, ophthalmology, tissue viability, infectious diseases, and pharmacy 1
• Identify high-risk factors: drug triggers, underlying malignancy, or previous stem cell transplant 1
• Calculate SCORTEN for prognostic indicator 1
• Stop all potentially causative medications immediately 1

For Complicated Intra-Abdominal Infection

• Do NOT routinely use broad-spectrum antibiotics for all children with fever and abdominal pain when suspicion of complicated infection is low 1, 4
• If complicated intra-abdominal infection confirmed, acceptable regimens include 1:
  • Aminoglycoside-based regimen
  • Carbapenem (imipenem, meropenem, or ertapenem)
  • Piperacillin-tazobactam or ticarcillin-clavulanate
  • Advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole

Pain Management

• Provide immediate pain relief and do NOT withhold while awaiting diagnosis, as pain control facilitates better examination without affecting diagnostic accuracy 4, 5
• For mild-moderate pain: oral NSAIDs if no contraindications 4
• For severe pain: intravenous opioid analgesics titrated to effect 4
• Analgesia particularly important if chest drain required for any pleural complications 1

Nutritional Support

• Ascertain if child can maintain adequate hydration and nutrition orally 1
• If not possible, insert nasogastric tube and institute nasogastric feeding immediately 1
• Record weight and repeat at frequent intervals (no less than weekly) 1

Critical Pitfalls to Avoid

• Never delay treatment while awaiting culture results in septic-appearing children, as early treatment improves outcomes and reduces mortality 3, 4
• Do not perform blind finger sweeps if foreign body suspected, as this may push objects farther into pharynx 1
• Avoid withholding pain medication while awaiting diagnosis—this is outdated practice that impairs examination 4, 5
• Do not routinely order broad-spectrum antibiotics for all children with fever and abdominal pain; reserve for confirmed complicated infections 1, 4
• Never use antibiotics for STEC O157 or Shiga toxin-producing E. coli, as this increases risk of hemolytic uremic syndrome 3

Disposition and Monitoring

• Transfer to pediatric intensive care unit if respiratory symptoms present, hemodynamic instability, or extensive skin involvement (>30% BSA) 1
• Continuous monitoring with repeated physical examinations in all cases 2
• Ensure care is developmentally appropriate with facilities to support patient and caregivers 1