Anthony L. Pearson-Shaver

Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis

The acute complications of diabetic ketoacidosis in children and adolescents are well recognized but not completely understood. Clinical studies have focused primarily on brain edema. We have investigated the prevalence and course of interstitial pulmonary edema in patients with severe diabetic ketoacidosis all of whom had uneventful clinical courses. High resolution computed tomography scans of the lungs were analyzed by determining the Hounsfield attenuation level and then converting to physical density values. All seven patients had evidence of interstitial pulmonary edema on the first scan, which was performed within 1 h of hydration and prior to receiving insulin; six of the seven patients had increased pulmonary density 6-8 h into treatment, and all had complete resolution of the interstitial changes at discharge. Our study suggests that subclinical interstitial pulmonary edema may be a frequent occurrence in children and adolescents with severe diabetic ketoacidosis and may very well be present prior to treatment. The study also supports the philosophy of cautious rehydration and the close monitoring of children and adolescents with diabetic ketoacidosis until a more complete understanding of this pathophysiologic event is achieved.

Delivering diagnostic quality video over mobile wireless networks for telemedicine

In real-time remote diagnosis of emergency medical events, mobility can be enabled by wireless video communications. However, clinical use of this potential advance will depend on definitive and compelling demonstrations of the reliability of diagnostic quality video. Because the medical domain has its own fidelity criteria, it is important to incorporate diagnostic video quality criteria into any video compression system design. To this end, we used flexible algorithms for region-of-interest (ROI) video compression and obtained feedback from medical experts to develop criteria for diagnostically lossless (DL) quality. The design of the system occurred in three steps-measurement of bit rate at which DL quality is achieved through evaluation of videos by medical experts, incorporation of that information into a flexible video encoder through the notion of encoder states, and an encoder state update option based on a built-in quality criterion. Medical experts then evaluated our system for the diagnostic quality of the video, allowing us to verify that it is possible to realize DL quality in the ROI at practical communication data transfer rates, enabling mobile medical assessment over bit-rate limited wireless channels. This work lays the scientific foundation for additional validation through prototyped technology, field testing, and clinical trials.

Acute rhabdomyolysis complicating status asthmaticus in children: case series and review.

Objectives: To describe a case series of 4 children who developed acute rhabdomyolysis as a complication of acute respiratory failure secondary to status asthmaticus. Methods: A retrospective review of all children who were admitted to our pediatric intensive care unit (PICU) with status asthmaticus from November 1998 through July 2004 was performed and all children who developed acute rhabdomyolysis, defined as a 5-fold increase above the upper limit of normal in the serum creatine phosphokinase (CPK) concentration (CPK ≥1250 IU/L), were identified. Demographic and clinical data were abstracted from the medical record. Results: During the study period, 108 children with status asthmaticus were admitted to our PICU (3.6% of all admissions). Four children (age 12-19 years) developed acute respiratory failure requiring mechanical ventilation, and all 4 of these children (3.7% of all children with status asthmaticus admitted to the PICU) developed acute rhabdomyolysis. The 4 children who developed acute rhabdomyolysis were older than the children with status asthmaticus, without rhabdomyolysis (median age 15 years vs. 5 years). Conclusions: Acute rhabdomyolysis complicating status asthmaticus may be more common than previously ascertained. We therefore suggest that CPK levels should be followed closely in all children with status asthmaticus and acute respiratory failure. The early presentation of rhabdomyolysis in the current series suggests that factors other than corticosteroids and neuromuscular blockers are potentially involved. Mechanical ventilation and older age seem to be significant risk factors for rhabdomyolysis, perhaps implicating a mechanism similar to the pathogenesis of severe exercise-related rhabdomyolysis. Further clinical study of the incidence and causative factors of rhabdomyolysis in this population is warranted.

A tale of two sisters.

A 4-year-old previously healthy African-Americangirlwas brought to a rural hospital emergency department (ED) with the acute onset of fever, vomiting, somnolence, and seizures. She seemed in her usual state of good health until she was found outside, by her father, near the family’s barn where she had been playing. She was lying unconscious with generalized tonicclonic movements. According to emergency medical services personnel, she had vomited ‘‘a few times’’ and had been incontinent of urine at the scene, although she was no longer seizing. Upon arrival in the ED, the child was obtunded and ill-appearing and exhibited labored respirations. Her vital signs included a rectal temperature of 39.58C; heart rate, 78 beats per minute; respiratory rate, 38 breaths per minute; blood pressure, 110/65 mmHg; and hemoglobin oxygen saturation, 93%. Her pupils were 1 to 2 mm in diameter and sluggishly reactive. The mucus membranes were moist with copious, white, frothy oral secretions. Her lung examination revealed bilateral wheezing with diminished breath sounds bilaterally. Cardiovascular examination was significant only for a low heart rate. Peripheral pulses were strong and equal bilaterally without brachiofemoral delay. She had no abdominal tenderness, distension, or hepatosplenomegaly.Her skin was warm and clammy to touch with capillary refill of less than 2 seconds. There was no rash. She did not open her eyes to voice or pain, but withdrew to pain. Her deep tendon reflexes were normal. Her initial laboratory parameters upon presentation to the ED were as follows: sodium, 141 mmol/L; potassium, 3.7 mmol/L; chloride, 112 mmol/L; bicarbonate, 20 mmol/L; calcium, 8.4 mg/dL; magnesium, 2.1 mg/ dL, phosphorus, 5.9 mg/dL; blood urea nitrogen, 16 mg/dL; creatinine, 0.6 mg/ dL; glucose, 233mg/dL; albumin, 3.6 g/ dL; total protein, 5.9 g/dL; alanine aminotransferase, 11 U/L; aspartate aminotransferase, 39 U/L; total bilirubin, 0.6 mg/dL; and alkaline phosphatase, 202 U/L. An arterial blood gas analysis was pH 7.20; PaCO2, 58 mm Hg; PaO2, 88 mm Hg; and base excess, 6.5 mmol/L. A complete blood count revealed hemoglobin of 10.1 g/dL; hematocrit, 30.4%; platelets, 213,000 cells/mL; and white blood cells, 1500 cells/mL. A chest radiograph showed a normal cardiothymic silhouette and bilateral opacities consistent with either aspiration pneumonitis or noncardiogenic pulmonary edema. Intravenous accesswas secured, and she is tracheally intubated for airway protection and mechanical ventilatory support. Computed tomography of the head and lumbar puncture were obtained, the results of which were both essentially normal. Ceftriaxone, 50 mg/kg, and phenytoin, 20 mg/kg, were administered parenterally. Shortly thereafter, the child’s 3year-old sister presented with a similar constellation of symptoms, including lethargy, vomiting, and diarrhea. Her temperature was 36.88C; heart rate, 83 beats per minute; respiratory rate, 28 breaths per minute; and blood pressure, 83/42 mm Hg. Her pupils were 1 mm in diameter, and her respirations were shallow. Intravenous access was secured, and 20 mL/kg normal saline was administered. She was tracheally intubated for airway protection and mechanical ventilatory support. Naloxone, 0.1 mg/kg, was administered parenterally to both children without any significant improvement in sensorium. Can you pick your poison? A Tale of Two Sisters Pick Your Poison