Federico Poropat

Combination of intranasal dexmedetomidine and oral midazolam as sedation for pediatric MRI

passage of the ETT, the length of the bougie should be long enough to accommodate the full length of the ETT as well as extend beyond the proximal end of the tube, so that an assistant can hold it firmly while threading the ETT. In children, one of the commonly used introducer is Cook’s 8 French Frova introducer with a length of 35 cm. It is recommended for ETTs with an internal diameter of 3.5 to 5 mm. The length of a pediatric Frova is adequate when used with endotracheal tubes of internal diameter up to 4.5 mm ID but its length falls short with larger tubes. The average length of 5 mm ID ETT from various manufacturers varies from 24 to 25 cm with the exclusion of the universal circuit adaptor, which makes it impossible to hold the proximal end of introducer once the ETT is railroaded over it (Figure 1). This necessitates discontinuing the current attempt of intubation. As the intubation attempts increase, the risk of airway trauma and desaturation also increases. To ensure smooth railroading of the ETT, the pediatric airway introducer should be at least twice the length of the ETT. Otherwise one simple solution to avoid these problems would be to use a preshortened tube cut to the length appropriate for the age and height of the child. The shortened ETT provides an additional benefit of reducing the airway resistance. Another option is to preload the regular length ETT on the introducer with its bent tip extending just beyond the bevel of ETT. The manufacturer recommends preloading of the ETT over Frova while using as an intubation aid. This technique provides ample length of the introducer beyond the proximal end of the tube but if tube exchange is needed due to improper size, the same problem of inadequate length will crop up; therefore, a shortened tube should be kept standby. This simple step of shortening the ETT while using pediatric Frova introducer can avoid unwanted stress while managing a difficult airway in children and smoothen the process of intubation.

A Boy with Acute Strabismus

Figure 2. Magnetic resonance imaging shows a lesion occupying one-half of the sphenoidal sinus with no involvement of other sinuses. A 12-year-old boy was admitted to the hospital with a 3-day history of strabismus, diplopia, and worsening of a headache of which he had been complaining for 3 months, without nocturnal awakenings. The headache worsened during the previous 2 weeks, after an upper respiratory tract infection, such that the analgesic therapy (paracetamol and codeine) was not effective anymore. There was no history of vomiting. In the previous period, he never had been febrile. On neurologic examination, we found a left esotropia without alterations of ocular movements (Figure 1), a faltering walk probably due to diplopia, and a bilateral papilledema; visual acuity was normal. Blood tests revealed only a mildly elevated erythrocyte sedimentation rate. A magnetic resonance imaging scan ruled out a brainstem tumor but showed homogeneous semifluid material completely occupying half the sphenoid sinus, with no enhancement after contrast, in keeping with a flogistic event (Figure 2). A computerized tomography scan of the paranasal sinuses highlighted a well-delineated cystic formation with loss of bone continuity next to the sella turcica, a radiologic image compatible with a mucocele (Figure 3; available at www.jpeds.com). This diagnostic suspectwas confirmedby surgery (endoscopic sphenoidotomy). Sphenoid sinus mucocele is a rare condition accounting for 1%-2% of paranasal sinus mucoceles. The etiology is unknown; it could be due to sinus ostium obstruction following chronic sinus inflammation, polyposis, infections, or tumors. The highest incidence of sphenoid sinus mucocele is reported during the fourth decade of life, whereas it is rare in childhood when cystic fibrosis must be ruled out. Useful for

Teaching pain recognition through art: the Ramsay-Caravaggio sedation scale

BackgroundClinical observation is a key component of medical ability, enabling immediate evaluation of the patient’s emotional state and contributing to a clinical clue that leads to final decision making. In medical schools, the art of learning to look can be taught using medical humanities and especially visual arts. By presenting a Ramsay sedation score (RSS) integrated with Caravaggio’s paintings during a procedural sedation conference for pediatric residents, we want to test the effectiveness of this approach to improve the quality of learning.MethodsIn this preliminary study, we presented videos showing sedated pediatric patients in the setting of a procedural sedation lesson to two randomized groups of residents, one attending a lesson on RSS explained through the masterpieces of Caravaggio, the other without artistic support. A week later we tested their learning with ten multi-choice questions focused on theoretical questions about sedation monitoring and ten more questions focused on recognizing the appropriate RSS viewing the videos. The primary outcome was the comparison of the total number of RSS layers properly recognized in both groups. We also evaluated the appreciation of the residents of the use of works of art integrated with the lesson.ResultsEleven students were randomized to each group. Two residents in the standard lesson did not attend the test. The percentage of correct answers on the theoretical part was similar, 82% in the art group and 89% in the other (p > 0.05). No difference was found in the video recognition part of the RSS recognition test. Residents exposed to paintings shown great appreciation for the integration of the lesson with the Caravaggio’s masterpieces.ConclusionsAdding artwork to a standard medical conference does not improve the performance of student tests, although this approach has been greatly appreciated by residents.

Adolescent with painful vesicular otitis and vertigo

A 15-year-old girl presented with left ear pain and vertigo, exacerbated by head movements. She described vertigo as a sensation of motion of the environment. Physical examination showed hyperaemia and oedema of the auricle and of the external auditory canal. Persistent, spontaneous, horizontal, grade II right-beating nystagmus, under Frenzel’s glasses, was noted. Bedside examination of vestibulospinal reflexes (Romberg test, past pointing test, tandem, walking and stepping tests) showed a shifting towards the left, indicating a static imbalance. Oral therapy with ciprofloxacin at 20 mg/kg in two doses was started. Three days later, ear pain and vertigo persisted and worsened. On re-evaluation, a painful vesicular and crusty rash in the left auditory canal and auricle was noted (figure 1). Figure 1 Vesicular and crostous lesions of the auditory canal and concha, with oedema and hyperaemia of the ear, pathognomonic of varicella zoster virus reactivation. Which of the …

Painful swelling of the clavicle

A 14-year-old boy was admitted for a painful swelling of the middle third of his right clavicle lasting 3 days. He denied any trauma and/or fever. Physical examination showed a soft swelling, without calor or hyperemia of the skin. Pain was exacerbated by bone percussion and by right arm abduction movements. Bone X-ray was normal, but an ultrasound showed enlargement with hypoechoic soft tissue and enhancement of the vascular signal with Doppler technique (figure 1). The blood tests were normal, with no elevation of erythrocyte sedimentation rate (ESR) and C reactive protein (CRP). Figure 1 Ultrasound of the right sternoclavicular joint showing an enlargement of the articular capsule filled of hypoechoic inflammatory tissue collected between the two bone heads (red arrows). Which of the following do you think is the diagnosis in this patient? 1. Infective osteomyelitis 2. Chronic recurrent multifocal osteomyelitis (CRMO) 3. Tietze syndrome (TS) 4. Primary chest wall tumour Which is the next diagnostic step to confirm the clinical …

Acute small bowel obstruction in a child with a strict raw vegan diet

A 1-year-old toddler was admitted with a 12-hour history of repeated vomiting. He had not passed stools for the past 3 days, or flatus in the last 24 hours. Physical examination showed abdominal distention without pain or guarding. An abdominal X-ray showed multiple air fluid levels with a distended small bowel (figure 1). A video-assisted laparoscopy showed dilated small bowel loops. Figure 1 Multiple air fluid levels and distended small bowel loops with no …

Bannayan-Riley-Ruvalcaba syndrome: an uncommon case of hematochezia in a 3-year-old boy.

p e A 3-year-old boy presented with intermittent, self-limiting episodes of hematochezia. History revealed large for gestational age and macrocephaly. Physical examination was normal except for 2 café-au-lait spots on the right thigh, 1 pigmented macula on the glans penis (Fig. 1), and mild mental retardation. Colonoscopy, upper endoscopy, and capsule endoscopy identified multiple intestinal polyps (Fig. 2). Bannayan-Riley-Ruvalcaba syndrome (BRRS) was suspected. BRRS is a rare, dominant autosomal inherited disorder characterized by the presence of macrocephaly, lipomatosis, hemangiomata, intestinal hamartomatous polyps, pigmentary spotting of the penis and mental retardation (1–3). Most specific of the syndrome is freckling of the glans penis, described in 85% of affected males (4) that is not always present at birth but may appear later in childhood. The gastrointestinal tract is involved in 35% to 40% of the patients, with the development of intestinal hamartomatous polyps that can cause anemia, chronic diarrhea, and small bowel intussusception (5). A mutation of the phosphatase and tensin homolog (PTEN) gene, a tumor suppressor gene located on chromosome 10, is reported in 50% to 60% (6). Cancer surveillance in these patients is debated; some authors have suggested that polyp identified with capsule endoscopy.