Ann L. Harwood-Nuss

RETINAL HEMORRHAGE IN THE YOUNG CHILD: A REVIEW OF ETIOLOGY, PREDISPOSED CONDITIONS, AND CLINICAL IMPLICATIONS

Retinal hemorrhage is a frequent finding in child abuse, but may also be associated with cardiopulmonary resuscitation, accidental trauma, and a variety of illnesses such as blood dyscrasias and infections. Although it is imperative that child abuse be considered in all children who present with retinal hemorrhages, whether retinal hemorrhages can be attributed to cardiopulmonary resuscitation in suspected cases of abuse poses a dilemma. The etiologies of retinal hemorrhage as well as the literature presently available to support or refute the various diagnoses are discussed. Guidelines for funduscopic examination in the Emergency Department as well as a clinical classification of retinal hemorrhage are provided. In addition, guidelines are suggested for the appropriate clinical investigations in children with retinal hemorrhages.

Comparison of pH and carbon dioxide tension values of central venous and intraosseous blood during changes in cardiac output

ObjectiveTo compare the pH and Pco2 values determined from of simultaneously corrected samples of central venous and intraosseous blood during sequential changes in cardiac output. DesignProspective, descriptive study. SettingAn animal laboratory in a university medical center. SubjectsFourteen mixed breed 4-wk-old piglets. InterventionsAnimals were anesthetized with ketamine hydrochloride and neuromuscular blockade was induced by the administration of pancuronium bromide. After endotracheal intubation and the institution of mechanical ventilation, a 4-Fr pulmonary artery catheter and a carotid artery cannula were inserted via a cutdown into the right neck of each piglet. A 16-gauge intraosseous needle was inserted into the anteromedial surface of the right tibia. Measurements and Main ResultsCentral venous and intraosseous blood gas samples were obtained simultaneously with thermodilution cardiac output measurements. Cardiac output measurements were as follows: during steady state (0.80 ± 0.14 L/min), after volume loading of 15 mL/kg (1.00 ± 0.25 L/min), after three successive bleeds of 15 mL/kg each at 30-min intervals (0.70 ± 0.28, 0.54 ± 0.22, and 0.43 ± 0.16 L/min, respectively) and at exsanguination (unrecordable). Paired t-tests demonstrated no significant differences in pH and Pco2 values between intraosseous and central venous samples under all study conditions. Limits of agreement for difference in Pco2 between sites, within the range of cardiac outputs studied, were −12.86 to 11.38 torr (-1.71 to 1.46 kPa) and for pH were −0.09 to 0.15. ConclusionsIntraosseous blood samples can be obtained without difficulty even during extreme hypovolemia. The pH and Pco2 values of intraosseous and central venous blood samples were similar under all study conditions. Intraosseous blood may be a useful alternative to central venous blood to assess tissue acid-base status during hemorrhagic shock and other low-flow states. (Crit Care Med 1994; 22:1010–1015)

Bacterial meningitis in infants and children: A review

Emergency physicians are often required to evaluate febrile infants and children with no obvious source of infection. Most have uncomplicated viral illnesses. It is imperative, however, to identify the child with potentially life-threatening bacterial meningitis. The clinical presentation of meningitis is variable and depends on many factors. These variables are discussed as well as the indications for lumbar puncture and guidelines for laboratory evaluation. Recommendations for antibiotic selection and dosages are provided. The clinical trials regarding the use of dexamethasone are also reviewed.

Urolithiasis in a Child: An Uncommon Presentation of an Uncommon Disease☆☆☆★

Urolithiasis in children is uncommon. We present the case of a 10-year-old boy with anuria resulting from an obstructing stone in the urethral meatus. There are no previously reported cases of pediatric urolithiasis presenting with anuria. We review urolithiasis in children, including predisposing factors, clinical features, stone composition, and natural history. The diagnosis may be confusing in younger children but should be considered with complaints of flank or abdominal pain, hematuria, and urinary tract infection.

Paraesophageal hernia in an elderly woman

We present a case of an elderly woman with a paraesophageal hernia. This is an uncommon type of hiatal hernia and may result in a surgical emergency if incarceration, obstruction, or strangulation is present. Our patient presented with a clinical picture consistent with myocardial ischemia. We discuss the differential diagnosis, the pathophysiology, complications, diagnostic studies, and treatment of this disease.