case presentation
DESCRIPTION
Ali Al BlushiTRANSCRIPT
OBJECTIVESOBJECTIVES
CASE
LETRETURE REVIEW
CaseCase
ON 16/2/2010 @ 08:30 hrs
S. A , 2 y.o boy H/O Vomiting
24/11/2009
HX PRIMARY SURVEY
VOMITINGABCDE
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
MONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HxHx
Intermittent , started 2 wks agoDx = AGEThis time: started middle of night 10 hrs agoThis is the 3rd episode h/o low appititeh/o loss of wt
HxHx
NORMAL BOWEL MOVEMENT , NO BLOOD OR MALENA
NO URINARY SYMPTOMS
NO H/O FEVER
NO COUGH OR SOB
NO H/O FITS
HxHx
PMHx:
1. 3/12 ago, had similar episode lasted for a wk
2. Unremarkable antenatal Hx3. Immunization = upto date
HxHx
Not on any drugs
No h/o allergy
No h/o travel
No similar Hx in family
24/11/2009
HX PRIMARY SURVEY SECONDARY SURVEY
VOMITINGABCDEMONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HEAD & NECKRESPCVSABDCNSMSKSSKIN
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
SECONDRYSECONDRY SURVEYSURVEY
H&NNO ABNORMAL FEATURESMODERATELY DEHYDRATEDNO PALLORNO JAUNDICENO L.NSUPPLE NECKNO MENINGEAL SIGNS
SECONDRY SURVEYSECONDRY SURVEY
R.SGOOD A.E, CLEAR
CVSPULSES= REGULAR RATE & RHYTHMS1 S2 NORMAL, NO MURMERS
SECONDRY SURVEYSECONDRY SURVEY
P/A
SOFT, NON TENDERNO ORGANOMEGALYNORMAL B.SHERNIAL ORIFICES = INTACTPR = NOT DONEGENETALIA = NORMAL
SECONDRYSECONDRY SURVEYSURVEY
CNS :
• AWAKE• FOLLOWING COMMANDS• MOVING ALL EXTREMITIES• CN INTACT
SECONDRYSECONDRY SURVEYSURVEY
EXTREMITIES:
WELL PERFUSED, NO CLUBBING OR CYANOSIS OR EDEMA
CAP REFIL = 3 SEC
24/11/2009
HX PRIMARY SURVEY SECONDARY SURVEY
DDX
VOMITINGABCDEMONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HEAD & NECKRESPCVSABDCNSMSKSSKIN
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
24/11/2009
HX PRIMARY SURVEY SECONDARY SURVEY
DDX LAB RX
DISPOSTION
VOMITINGABCDEMONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HEAD & NECKRESPCVSABDCNSMSKSSKIN
RADIOLOGY
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
INVESTIGATIONSINVESTIGATIONS
CBC,, Hb= 11.0 (LOW MCV & MCH) Plt= 388 WBC= 6.6LFT,, WNRU/E,, WNRURINE,, NADAMYLASE ,, WNR
INVESTIGATIONSINVESTIGATIONS
CHEST/ ABDOMEN X-RAY:
NORMAL MEDIASTINUM NO CARDIOMEGALY CLEAR CHEST NO SIGNS OF BOWEL OBSTRUCTION NO A.U.D
ECG:
SINUS BRADY.
24/11/2009
HX PRIMARY SURVEY SECONDARY SURVEY
DDX
VOMITINGABCDEMONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HEAD & NECKRESPCVSABDCNSMSKSSKIN
LAB RADIOLOGY
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
OBSERVATIONOBSERVATION
DURING OBSERVATION, CHILD HAD TCS
TREATED WITH IV. LORAZEPAM
NEXTNEXT?? ??
CT BRAIN ( NON CONTRAST) :
OBSTRUCTIVE HYDROCEPHALUS
POSTERIOR FOSSA MASS ? TUMOR
24/11/2009
HX PRIMARY SURVEY SECONDARY SURVEY
DDX LAB RX
DISPOSTION
VOMITINGA&CBCDEMONITER,O2, IV LINES, ECG
MORE HXHPCAMPLE
HEAD & NECKRESPCVSABDCNSMSKSSKIN
RADIOLOGY
VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8
Rx & DISPOSITIONRx & DISPOSITION
CONTINUED TO HAVE SEIZURES ,, Rx WITH LORAZEPAM
INTUBATED
REFERED TO NEUROSURGERY
PT HAD MRI BRAIN,, CONFIRMED TUMOR
TUMOR RESECTED
INTRODUCTIONINTRODUCTION
Tumors in posterior fossa are considered critical brain lesions. This is, primarily, because of the limited space within the posterior fossa and the potential involvement of vital brain stem nuclei.
Some pts should undergo emergency operation, especially if they present with acute symptoms of brain stem involvement or herniation.
INTRODUCTIONINTRODUCTION
Posterior fossa tumors are more common in children than the adults.
Between 54% and 70% of all childhood brain tumors originate in the posterior fossa.
About 15-20% of brain tumors in adults occur in the posterior fossa.
INTRODUCTIONINTRODUCTION
Certain types of posterior fossa tumors, such as medulloblastoma, pineoblastoma, ependymomas, primitive neuroectodermal tumors (PNETs), and astrocytomas of the cerebellum and brain stem, occur more frequently in children.
Some glial tumors, such as mixed gliomas, are unique to children. They are located more frequently in the cerebellum (67%) and are usually benign.
PRESENTATIONPRESENTATION
BRAIN TUMOURS IN PAEDs CHARACTERISTICALY PRESENT WITH SYMPTOMS OF INCREAED ICP CAUSED BY HYDROCEPHALUS
90% OF PTs WITH MEDULLOBLASTOMA OR CEREBELLAR ASTROCYTOMA & 65% WITH EPENDYMOMAS PRSENT WITH HYDROCEPHALUS SYMPTOMS
PRESENTATIONPRESENTATION
SYMPTOMS; HEADACHE, VOMITING, IRRITABILITY , LETHERGY
MORE COMMON IN THE MORNING BECAUSE OF RECUMBENCY & RELATIVELY ELEVATED PaCO2 INCREASES ICP
BRADYCARDIA IS OMINOUS BECAUSE IT SIGNIFIES VENTILATORY ARREST IS IMMINENT
InvestigationsInvestigations
CT is the first to be doneDetect 95% of brain tumors
CT scan of the posterior fossa is inferior to MRI in diagnostic value because of the artifact produced from the surrounding thick bone. However, CT scan is helpful for postoperative follow-up
ManagementManagement
INDICATIONS FOR SURGERY;
To decompress the post. fossa for the purpose of relieving pressure on the brain stem and/or to release ICP & avert the risk of herniation
To diagnose the tumor based on histopathology
To determine further plan of management depending on the nature of the tumor
ManagementManagement
When indicated, to treat hydrocephalus by shunting cerebrospinal fluid (CSF) to the peritoneal cavity