Michael O. Gayle

Treatment of critical status asthmaticus in children

Status asthmaticus is complex in its etiology and pathophysiology and may be associated with significant morbidity and mortality. Although there are many therapeutic options, specific inhaled beta 2-agonists, corticosteroids, and oxygen remain the mainstay of therapy. Several new drugs and some older drugs are being used in management; their exact role in treatment at present, however, relies largely on personal preferences. Innovative methods of providing ventilatory support are also emerging. What is quite clear is the fact that involvement of specialists (pulmonologists and intensivists) early in the course of severe status asthmaticus is needed to ensure optimal management and possibly favorable outcomes.

Jugular venous bulb catheterization in infants and children

Cross-brain oxygen extraction may be altered by coma, hyperventilation, hypothermia, or barbiturates, and has been demonstrated in adults and more recently in children to be related to functional neurologic recovery after a variety of brain injuries. However, measurement of cross-brain oxygen extraction in children is currently not a part of routine clinical care, partly because there have been no published attempts relating the technique of jugular venous bulb (JVB) catheterization and its complication in children. We catheterized the JVB to measure cerebral venous oxygen content and calculate cross-brain oxygen extraction in 26 deeply comatose neonates and children ranging in age from a few hours to 14 yr. Bedside catheterization using the Seldinger technique was successful in 25 children, with standard venous cutdown necessary in the remaining child. All JVB catheterizations were performed with parental consent and during continuous monitoring of the intracranial (ICP) or fontanelle, as well as arterial, pressure. ICP was not significantly altered by the cannulation procedure in any of the children studied, although the cannulation occurred early in the childs course when ICP was well controlled. Inadvertent carotid artery puncture with bleeding controlled by local pressure occurred in four children, and catheter malposition was confirmed on lateral skull xray in two others. Jugular venous bulb catheters remained in place for 2 to 7 days (average 3) and malfunction or obstruction of the catheter did not occur. Organisms were grown from three of 26 catheter tips submitted for culture, with peripheral blood cultures also positive for the same organisms in two of these.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Evaluation of the role of comparison radiographs in the diagnosis of traumatic elbow injuries.

This study attempted to determine whether comparison radiographic views of the uninjured elbow result in increased diagnostic accuracy. Physicians (one junior and one senior orthopaedic resident and an orthopaedic surgeon) were provided with a short clinical summary and asked to interpret radiographs of the injured elbow (IE) or both the injured and uninjured elbow (UE) in a randomized fashion from 25 children with elbow injuries. The overall percentage of correct diagnoses (one vs. two elbow radiographs) were as follows: orthopaedic surgeon, 80 versus 96%; for junior resident, 80 versus 84%; and for senior resident, 84 versus 88% (p > 0.05). Kappa scores for interobserver variability and intrarater agreement were in the high range (0.756 to 0.904, kappa = 0.08). Clinically relevant diagnoses were missed by trainees (not the orthopaedic surgeon) whether radiographs of IE or both IE and UE were interpreted. Incorrect radiograph interpretations were due to false positives in 39 of 40 cases. Comparison radiographs of the UE were not useful in improving diagnostic accuracy in elbow trauma. However, although they may be necessary in some instances, routine radiographic examination of the UE is not warranted.

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)

The evaluation of pediatric trauma care using audit filters.

Objective To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. Design Descriptive review of concurrent audit. Setting A tertiary care referral adult and pediatric trauma center. Patients All pediatric trauma victims in the trauma registry (includes patients ≤14 years old, who died or were hospitalized for ≥24 hours) Interventions None. Measurements and main results Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. Conclusion Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

Drug therapy approaches in the treatment of acute severe asthma in hospitalised children.

Acute severe paediatric asthma remains a serious and debilitating disease throughout the world. The incidence and mortality from asthma continue to increase. Early, effective and aggressive outpatient therapy is essential in reducing symptoms and preventing life-threatening progression. When complications occur or when the disease progresses to incipient respiratory failure, these children need to be managed in a continuous care facility where aggressive and potentially dangerous interventions can be safely instituted to reverse persistent bronchospasm. The primary drugs for acute severe asthma include oxygen, corticosteroids, salbutamol (albuterol) and anticholinergics. Second-line drugs include heliox, magnesium sulfate, ketamine and inhalational anaesthetics. Future therapies may include furosemide, leukotriene modifiers, antihistamines and phosphodiesterase inhibitors. This review attempts to explore the multitude of medications available with emphasis on pharmacology and pathophysiology.

Assessment of respiratory distress in the asthmatic child: when should we be concerned?

The physician caring for the acutely ill asthmatic child has a wide variety of signs and systems to assist in assessment. An assessment of the severity of the disease should be based on the medical history, and signs and symptoms due to hypoxia on various target organs. Laboratory evaluation, while helpful, has limited applicability in the young child but should be used as an adjunct to clinical assessment where necessary. Based on the history, physical examination, and laboratory assessment (when appropriate), acute asthma symptoms should be categorized as mild, moderate, or severe. Treatment then can be tailored to disease severity.

Delayed presentation of traumatic arterial vasospasm.

Traumatic arterial vasospasm with no surrounding anatomic damage is a rare finding. Delayed presentation of arterial vasospasm several days from the inciting event is also rare. However, when the diagnosis of arterial vasospasm is considered, evaluation and treatment must be initiated promptly to avoid prolonged ischemia to the extremity. We present an 11-year-old female who presented with a delayed presentation of arterial vasospasm, and also review the literature.