Edwin M. Frieberg

Spontaneous subcutaneous emphysema

Subcutaneous emphysema is an unusual complication of bronchiolitis. The investigators describe a patient with bronchiolitis who developed extensive subcutaneous emphysema. Despite an alarming appearance, the patient recovered with symptomatic care and observation. Review of the literature shows a multitude of causes of subcutaneous emphysema. The vast majority of cases resolve without intervention.

Ventricular septal avulsion and ventricular septal defect after blunt trauma

Traumatic ventricular septal defect is an uncommon complication of blunt chest trauma. We report a case of ventricular septal avulsion, associated with traumatic ventricular septal defect and the associated management concerns.

Functional Adrenal Insufficiency Complicating an Overdose of Naproxen and Ibuprofen

Nonsteroidal anti-inflammatory drugs (NSAIDs) are extensively used for their analgesic, antipyretic and antiinflammatory properties. NSAIDs like naproxen and ibuprofen are readily available in most homes with more than 30 billion doses consumed annually. Though severe complications from naproxen and ibuprofen overdose are rare, fatalities from massive overdose (especially with ibuprofen) have been reported. We report the case of a previously healthy 15-year-old male who overdosed on naproxen and ibuprofen. He developed severe metabolic acidosis complicated by fluid and vasopressor refractory shock. The possible development of functional adrenal insufficiency (FAI) in patients with NSAID overdose and the salutary role of corticosteroid replacement in such cases are discussed.

High-Dose Tissue Plasminogen Activator, Topical Nitroglycerin, and Heparin for Severe Ischemic Injury in a Neonate

Arterial occlusion resulting from thrombi, emboli, or vasospasm is one of several complications of femoral artery (FA) catheterization in neonates. Severe ischemia of the affected limb might result in amputation, limb deformity, and loss of function if aggressive treatment is not undertaken. Because surgery is the last resort and is of limited benefit in neonates, thrombolytic therapy and anticoagulation are the initial treatments of choice. To our knowledge, we are reporting the first successful use of a combination therapy consisting of tissue plasminogen activator (tPA), 2% topical nitroglycerin (NGC), and heparin for the treatment of life-threatening ischemic complications of FA catheterization in a neonate. Previous reports were either limited to isolated use of 2% NGC or use of tPA with or without heparin for treatment of ischemia in neonates.

Posttraumatic Superior Ophthalmic Vein Thrombosis in a 2 Year Old

Abstract Superior ophthalmic vein thrombosis (SOVT) usually results from inflammatory, infectious, or malignant causes. This case describes a 2-year-old boy with severe prolapsing chemosis and proptosis due to thrombosis of the right superior ophthalmic vein resulting from midfacial and right orbital fractures 1 week after the initial trauma. Magnetic resonance imaging and internal carotid artery angiogram are essential in the diagnosis of SOVT. The literature on issues surrounding this case was reviewed with emphasis on the diagnostic evaluation, differential diagnoses, and management of posttraumatic SOVT.

Fatal Vibrio vulnificus sepsis in vertically acquired hepatitis C.

P ostoperative management of esophageal atresia (EA) frequently mandates serial dilations and application of local antifibrotic agents to control recalcitrant anastomotic strictures. Recently, temporary esophageal stenting has been described to maintain patency (1–4). Indwelling foreign material has an associated risk of erosion, and this must be considered when managing patients with anastomotic strictures after long-gap EA repair. We report 2 cases of arterioesophageal fistula formation and massive upper gastrointestinal bleeding (UGIB) related to stent placement after EA repair, each with unrecognized aberrancy of the right subclavian artery (ARSA). Based on these events, the authors advise that esophageal stents be placed only after detailed imaging studies rule out vascular aberrancy.

An Infant With Tachypnea

A 9-month-old patient presented to the pediatric emergency department with difficulty breathing after being seen briefly in clinic. His mother first noticed his symptoms of excessive drowsiness and lack of appetite 2 days prior. These symptoms would later progress to vomiting and difficulty breathing. The mother denied a fever and diarrhea in the last week, but did state the child had simultaneous ear infections treated with a 10-day course of amoxicillin 3 weeks ago. The mother did recount recent introduction of solid food and a father-in-law with type 1 diabetes mellitus. Initial evaluation in the emergency department revealed tachypnea, tachycardia, intercostal retractions, decreased capillary refill and peripheral pulses. Given the patient’s severe dehydration, respiratory distress, and the fact that he met SIRS (systemic inflammatory response syndrome) criteria, intravenous access was obtained and the patient was given a bolus of normal saline and intubated. Initial laboratory tests revealed bicarbonate of 8 mmol/L, glucose of 431 mg/dL, and an ammonium level of 109 mcg/dL. A venous blood gas (VBG) was obtained that showed an appreciable anion gap and a pH of 6.9. At this point the patient was determined to most likely be in DKA and insulin was given. Urinalysis would later confirm the diagnosis of diabetic ketoacidosis (DKA) by meeting criteria of a pH less than 7.3 or bicarbonate less than 15 mmol/L, glucose greater than 200 mg/dL, and presence of urine ketones. Subsequent VBG would reveal improvement in the patient’s blood pH. The patient continued to improve clinically, was extubated the following day, and released from the hospital 4 days later.

Acute Onset of Multi-Organ System Dysfunction:

A 7-year-old boy with no significant past medical history was transported to an outside emergency department by emergency medical services after multiple episodes of emesis followed by a witnessed 10-minute episode of “shaking all over.” In the emergency department, the patient was found to be profoundly acidotic with an arterial pH of 6.9, bradycardic (heart rate 50 beats/min), hypotensive (blood pressure 69/28 mm Hg), and hyperglycemic (serum glucose of 305 mg/dL). A preliminary diagnosis of diabetic ketoacidosis was established. Therapy was initiated with dextrose-containing intravenous fluids and a regular insulin drip. Following initial interventions targeted at stabilization of the patient’s condition, he was transferred to our pediatric intensive care unit for further evaluation and management. On arrival, the patient’s adoptive mother reported that he had been well-appearing up until shortly before the emesis began, when he became tired and sluggish. She denied any recent illnesses, fevers, sick contacts, or possible ingestions. The only medications reported to be in the home were aspirin, metformin, and prenatal vitamins. Physical exam revealed a well-developed boy who was drowsy and irritable. Vital signs included a temperature of 99°F, heart rate of 82 beats/min, blood pressure of 78/57 mm Hg, respiratory rate of 40 breaths/min, and oxygen saturation of 100% on room air. Pupils were equal and reactive and mucous membranes were dry. Cardiac exam was significant for bradycardia with strong pulses and normal capillary refill. Abdominal exam was benign. Neurologic exam was notable for a Glasgow Coma Score of 14 secondary to confusion; reflexes, motor, and sensory exams were unremarkable. Laboratory evaluation revealed negative serum and urine ketones, metabolic acidosis with arterial pH of 7.156, anion gap of 19, lactic acid of 10 mmol/L, serum glucose of 159 mg/dL, sodium 143 mmol/L, bicarbonate 14 mmol/L, potassium 4.1 mmol/L, magnesium 2.3 mg/dL, creatinine of 2.3 mg/dL, serum osmolarity of 301 mosm/kg, and negative urinary toxicology screen. Cerebrospinal fluid analysis was unremarkable. Electrocardiogram revealed junctional rhythm with a rate of 78 beats/min (Figure 1). Echocardiogram revealed normal anatomy and biventricular function. The patient was started on intravenous ceftriaxone and dopamine infusion at 5 μg/ kg/min to maintain systemic blood pressure. The patient’s mental status deteriorated over the several hours following admission, requiring elective intubation and mechanical ventilation. Persistence of hypotension and onset of oliguria necessitated increasing doses of dopamine and the addition of intravenous norepinephrine at 0.01 μg/kg/min. After a period of 18 hours following admission, as infectious or cardiac causes of the patient’s shock became increasingly unlikely, mass spectrometry of the urine was performed in the search for a toxic cause. Urine mass spectrometry revealed diltiazem, a calcium channel blocker (CCB).

Intensive care unit course of infants and children after cranial vault reconstruction for craniosynostosis

BackgroundCraniosynostosis (CSS) results from the premature closure of one or more cranial sutures, leading to deformed calvaria at birth. It is a common finding in children with an incidence of one in 2000 births. Surgery is required in order to release the synostotic constraint and promote normal calvaria growth. Cranial vault remodeling is the surgical approach to CSS repair at our institution and it involves excision of the frontal, parietal, and occipital bones. The purpose of this article is to describe the post-operative course of infants and children admitted to our PICU after undergoing cranial vault remodeling for primary CSS.FindingsComplete data was available for analyses in only 82 patients, 44 males (M) and 38 females (F); M: F ratio was 1:1.2. Patients (pts) age in months (mo) ranged from 2 mo to 132 mo, mean 18.2 ±-24.9 mo and weights (wt) ranged from 4.7 kg to 31.4 kg, mean 10.24 ± 5.5 Kg.. Duration of surgery (DOS) ranged from 70 minutes to 573 minutes mean 331.6 ± 89.0 minutes. No significant correlation exist between duration of surgery, suture category, patients age or use of blood products (P > 0.05). IOP blood loss was higher in older pts (P < 0.05) and it correlates with body temperature in the PICU (P < .0001). Post-op use of FFP correlated with intra-operative PRBC transfusion (P < 0.0001). More PRBC was transfused within 12 hrs-24 hrs in PICU compared to other time periods (P < 0.05). LOS in PICU was < 3 days in 68% and > 3 days in 32%. Pts with fever had prolonged LOS (P < 0. 05); re-intubation rate was 2.4% and MVD were 1.83 days. Repeat operation for poor cosmetic results occurred in 9.7% of pts.ConclusionsPost-op morbidities from increased use of blood products can be minimized if cranial vault remodeling is done at a younger age in patients with primary CSS. PICU length of stay is determined in part by post-op pyrexia and it can be reduced if extensive evaluations of post-op fever are avoided.