Transcript - Catalyst
Case Conference: Pediatric Critical Care Mary King, MD, MPH Assistant Professor Pediatric Critical Care Medicine Harborview Medical Center and Seattle Children’s Pediatric Critical Care Cases Case 1 HPI • 7 day old female presents to nurse midwife with lethargy, decreased PO intake, no wet diapers today • History reveals child has not seen a doctor yet as this was a home delivery, no U/S, routine delivery • What should be on your differential diagnosis for this lethargic 7 day old neonate? Differential Dx Differential diagnosis of a lethargic neonate: FEN/GI: Uremia, hypoglycemia, hypothyroid, adrenal insufficiency CV: Congenital heart disease, Myocarditis ID: Sepsis, Meningitis, UTI, necrotizing enterocolitis Neuro: NAT, IVH, Seizure, toxin What would you like to specifically know on PE? Vitals • • • • • HR 200, sinus BP 50/28 O2 sat 89% RR 70 T36.0 PE • • • • • • Lethargic baby not interacting Fast unlabored breathing with mild retractions No peripheral pulses, 1+ femoral pulses + systolic murmur at LUSB Abdomen soft No rashes, appears pale • What would you like to do for this child? • What is your most likely diagnosis? Course • What would you like to do for this child? – Call 911, immediate transfer to tertiary peds center – IV access, NS bolus 20 cc/kg, check blood glucose, administer PGE (prostaglandins) – Echocardiogram – Rule Out Sepsis (Bcx, Ucx, LP, cefotaxime, ampicillin) Initial workup • • • • ABG: 6.9/20/22/5/-21 Glucose: 169 Na: 131 WBC: 14K Diagnosis • What is your most likely diagnosis? – Congenital Heart Disease • Left ventricular Outflow Tract Obstruction – ie) Aortic Stenosis • Cyanotic heart disease with incr pulmonary Q – ie) HLHS – Neonatal sepsis Course • ECHO: Aortic stenosis, PDA barely open, poor systolic LV function • Continue prostaglandins • Place a 4F/5cm femoral CVL • Initiate Milrinone • PDA opens fully • Aortic valvuloplasty performed • Acidosis, perfusion and LV function improve • Goes home 3 weeks later Pediatric Critical Care Cases Case 2 HPI • 23 month old male with Trisomy 21 • Given small piece of toffee candy by mom • Mom tried to get it out of his mouth by sweeping mouth with her pinky finger • Child immediately began choking, gagging, making poor respiratory effort • Child turned blue and became unresponsive Prehospital course • 911 was called • Family friends started bystander CPR • Medics arrived and found a blue child with an undetectable O2 saturation with a HR = 40 • A,B: Manually bagged and intubated the child • C: CPR and placed an intraosseus needle • HR and BP returned after 8 minutes of CPR • Valium given for agitation • Emesis at the scene Vitals • • • • • T 34.7 HR 126 BP 128/83 RR 30 SpO2 93% on FiO2 85% PE • RESP: – no chest rise on right – absent breath sounds on the right – scattered rhonchi on the left • CV: – sinus tachycardia, regular, no murmur – no hepatosplenomegaly – brisk capillary refill – 2+ pulses Labs Electrolytes: Na 137, K 4.5, Cl 105, CO2 23 BUN/Cr: 19/0.5 Glucose: 320 CBC: WBC 22, Hct 32, Plt 402 Lactate: 3.5 (0.5-1.6) ABG: 7.21 / 52 / 73 / 21 / -7 CXR CXR after ETT reposition Problem list? Problem list • Severe hypoxemic respiratory failure • Foreign body aspiration • Complete right mainstem obstruction and atelectasis • Likely aspiration pneumonitis • Status-post cardiopulmonary arrest • Trisomy 21 Plan? Plan • Emergent rigid bronchoscopy for foreign body removal • Supportive care via mechanical ventilator Hospital day 1 • OR with Otolaryngology for rigid bronchoscopy • A very gooey piece of English Toffee is removed from the right main bronchus with a large amount of inflammatory material • Child returns to the PICU CXR-post bronchoscopy Hospital day 2 • The next morning: – improved chest movement on right – improved aeration on right – scattered rhonchi throughout right – SpO2 95% on FiO2 40% (from 85%) CXR-hospital day 2 Hospital days 2-4 • • • • • • Weaned from the mechanical ventilator Extubated to mom’s arms ~ 24 hrs after bronch Weaned from nasal canula oxygen to room air No bed available on the floor for transfer Taking vigorous PO feeds Discharged from PICU to home with parents