Duygu Unkaracalar, MD

PGY-1

2,5 y/o female with grunting

HISTORY

HISTORY1 week h/o dry cough, clear runny nose, diarrhea (non-

bloody, no mucous), vomiting (NBNB), decrease PO intake

5 days ago PMD visit: Promethazine no improvement Last 3 days fever (Tmax: 102), productive cough2 days ago PMD visit: wheezing (+), b/l otitis media

Prednisolone, Albuterol, Azithromycin no improvementMotrin was given 1 hour prior to the ER visitDifficulty breathing, grunting started about 1/2 hour ago,

no PO, BM, vomiting or urine output todaySick contact (+) father had flu-like symptoms last weekNo travel, no pets or smoking

HISTORYBirth hx: FT, NSVD, no NICUPMH: Intermittent asthma ( x2 attacks/year, no hosp

or ER visits), no surgeries

Meds: Albuterol PRNUTD, no flu vaccine NKDAFH: non-contributory

PE

PEGeneral: Pt was in respiratory distress, grunting, perioral

cyanosis, GCS:15Vitals: RR: 56/min, HR: 143/min, sO2: 86%(on RA), T: 98,4 F, BP: 116/77 mm-HgHEENT: Perioral cyanosis, b/l Tms dull, oropharinx-tonsils

wnl, no LAPs Lungs: Tachypnea, B/L decrease breath sounds on the

bases(L>>R), intercostal retractions(+), wheezing (+), no rales

Heart: Tachycardia, RRR, S1,S2(+), no m/g/rAbd: Soft, (+) BS, NTND, no HSMExt: Warm, cap refill<2 sec, b/l good pulsesNeuro: Oriented x3, CNII-XII wnl, no lateralitazions, no

babinski, b/l DTRs wnl, no neck stiffness

Work-upCBCWBC: 6.1, Hb: 13, Htc: 38.4, Plt: 199 (83% N,

13% L, 4% M) CMP Na: 137, K: 3.7, Cl: 117, HCO3: 18, BUN:59, Cr: 1.0, Glu: 121, Ca:8.4, PO4: 5.5, Mg: 1.2, Alb: 2,

Prt:3.9, ALT:41, AST:36, ALP: 98, T./D.Bil: 0.6/0.4CRP: 8.4ABGpH: 7.35, pCO2: 44, HCO3: 19, BE: -2.2, pO2: 58,

sO2: 88%Flu A/B: (-), RSV: (-)Blood Culture CXR

Differential Diagnosis?

Differential DiagnosisRespiratory: Viral/Bacterial Pneumonia, Empyema,

Pulmonary TB, Hemothorax, Chylothorax, Pulmonary Embolism

Hem/Onc: NHL, Hodgkin Lymphoma, Sickle Cell Disease ( ACS)

CVS: Congestive Heart Failure (CHD, Myocarditis, Tamponade)

Renal: Nephrotic Syndrome, Renal FailureGI: Liver Failure, Hypoalbuminemia, PancreatitisRheumotology: SLE, JRA

ER Course 4L nasal O2 95%

Ceftriaxone 2 g IV

Solumedrol 60 mg IV

Alb/Atr neb x3

x1 Bolus

Laboratory

Admission to the PICU

PICU CourseBIPAP 95%L chest tube pH: 6.9, prt: 3.6g/dl, glu: 45.6mg/dl, cloudy 12500 WBC, 50 RBC gr(+) cocci in pairs, cx pendingRespiratory failure Intubated Acute renal failure ( 59/1, 37/0.7)Hemodialysis x2T: 37.6-39.8Subsequent CXRsworsen R pleural effusion R chest tubeRepeat CBCWBC: 59, Hb: 10.4, Htc: 29.6, Plt: 225

(78%PMNL, 17%L, 5%M) Ctx, Vancomycin, Famotidine, Alb neb, CS, Tylenol, TPNBlood cx: (-), H1N1, Flu A/B PCRs (-)

Pleural EffusionCollection of at least 10-20 mL of fluid in the pleural

spaceNormally 0.1-0.2 mL/kg of a colorless alkaline fluid,

which has less than 1.5 g/dL of protein Lymphocytes, macrophages, and mesothelial cells,

with an absence of neutrophilsInfection is the most common cause of pleural

effusion, 2. Congenital heart disease (CHD), 3.Malignancy

Classified as transudates and exudates

Pleural EffusionExudate Transudate

CloudypH < 7.2PP/SP > 0.5 or prt >3 g/dlP LDH/S LDH > 0.6 P Glu/S Glu < 0.5 or Glu<60mg/dl

Infection, pancreatitis (left-sided), rheumatologic diseases, chylothorax, malignancy, or trauma

ClearpH=7.45 or =serum pHPP/SP<0.5 or prt < 3 g/dlP LDH/S LDH < 0.6P Glu/S Glu > 0.5

Congestive heart failure, hypoalbuminemia, nephrosis, hepatic cirrhosis, and iatrogenic causes (eg, misplaced central line, complication of ventriculopleural shunt)

Pleural Effusion-LABCBC with diff, CRP, Blood culture, serum LDH, CMPSerology Mycoplasma, Legionella Ag, viralPleural fluid analysis gram staining and culture;

acid-fast staining and culture; cell counts; cytology; and determination of pH, protein, glucose, LDH, and triglyceride levels, Htc if hemothorax

ppdCoag tests

DefinitionsParapneumonic effusion

Pneumonia with evidence of effusion Uncomplicated (or simple)

free flowing pleural fluid Complicated

loculated pleural fluid Empyema

Pus in pleural space

Signs & Symptoms

FeverCoughDyspneaCyanosisLethargyPleuritic chest painAbdominal painVomiting

Decreased breath soundsDecreased chest

expansionCracklesFriction rubDullness on percussionTracheal shift

EtiologyPneumonia(viral,bacterial,tuberculosis,

mycotic)Lung abscessTraumaPostoperativeExtension of subphrenic abscessGeneralized sepsis

EtiologyThe most commonly –S. pneumoniae, S. aureus, and

group A streptococci (a complication of an infectious skin

disorder) Haemophilus influenzae-rarely (since H influenzae B

vaccine) Methicillin-resistant S Aureus is a concern in the older age

groupTuberculosis-worldwideAnaerobic infections -secondary to aspiration Fungal or mycobacterial infections – immunosuppressed

Loculated pleural effusion-USG B/L Pleural effusion-CT

TreatmentAntibiotics (10-14 days of intravenous antibiotics) Sulbaktam-

Ampicillin, 2nd generation cephalosporins (e.g Cefuroxime), 3rd generation cephalosporins (e.g Ceftriaxone), Vancomycin, Clindamycin

1-3 wks PO antibiotics-according to clinical picture and respondDiagnostic thoracentesis and chest tube drainage are

effective therapies in more than 50% of patients large effusion-greater than or equal to half the hemithorax, loculated effusion, thickened pleura on contrast-enhanced CT scanpositive Gram stain or culturepH less than 7.20 pleural fluid consists of pus

Multiloculated effusions (tPA- via chest tube, surgery)

PrognosisComplications are rare and prognosis is quite

good in pediatric populationRadiographic abnormalities by 3-6 months

following therapy PFT: Mild obstructive abnormalities were the

only findings observed in patients evaluated 12 years (±5) following recovery from empyema

Some increased bronchial reactivity

Follow-upAfebrile and improving clinicallythe IV drugs can

be switched to PO medications for 1-3 weeksChildren should be examined within 2-4 weeks after

discharge, depending on the patient's clinical statusSome experts recommend serial chest radiography

to ensure clearingSome perform CT scanning after the plain

radiographs clear

Back to the Case x3/day fever spikes T: 39.9 Urine Strep. Pneumonia Ag: (+) Repeat Blood cultures (-) Pleural effusion culture(-) ppd(-) Repeat CXRsimprovement Extubated on day 8 On day 9

Respiratory distress (RR: 55/min, sO2: 88%) Tachycardia (148-188/min) Hypotension (56-102/35-57 mm-Hg)-not enough improvement with Dopamine/Epinephrine

infusion Lactic acidosis (pH: 7.28, PCO2:40, HCO3:12, PO2: 45, BE:-10, LA:5) CVP:9-1823-24 mm-Hg) BiPAP not tolerated

Intubated again

PE FindingsAlert, in respiratory distressHR: 188/min, RR:55/min, sO2: 88%(2L NC), T:38.5,

BP: 56/35 mm-Hg, CVP: 24 mm-HgLungs: B/L decrease breath sounds, b/l intercostal,

subcostal retractions, b/l course breath sounds, no w/r/r

Heart: RRR, (+) S1, S2, muffled heart sounds, no m/r/g

Abd: Distended, (+)BS, NT, 4 cm HM(+), no SMExt: Cap refill 3 sec, b/l weak pulses, edema

What is the diagnosis?

Management?

Pericardial Effusion

Cardiac Tamponade

Cardiogenic Shock

Pericardial EffusionPericardial space contains approximately 20 mL of fluidMost commonly occurs as a direct extension of an infection

from an adjacent pneumonia or empyema, rarely hematogenously seed

Most cases occur in children younger than 4 yearsSymptoms are often nonspecific- fever, respiratory distress,

and tachycardia, chest painMost patients have a preceding or concurrent infection:

PneumoniaMeningitisAcute osteomyelitis Acute arthritis Soft tissue infections

Cardiac TamponadePericardial fluid accumulates rapidly enough or in

sufficient volume to impair diastolic fillingComplications: Pulmonary edema, shock, deathDuring tamponade, all 4 cardiac chambers compete

for space within the pericardium; Increased systemic venous and atrial pressure- HM,

edema, JVD, increased CVPIncrease pulmonary venous pressure- pulmonary

edema, hypoxia, respiratory distress

Cardiac TamponadeTachycardiaTachypneaHepatomegaly Diminished heart sounds JVDHypotensionIncrease CVPDelayed cap refillWeak pulses

Kussmaul sign-paradoxical increase in venous distention and pressure during inspiration

Pulsus paradoxus- >12 mm Hg or 9% drop in systemic blood pressure during inspiration

Cardiac Tamponade-Causes HIV infection Infection - Viral, bacterial , fungal Drugs - Hydralazine, procainamide, isoniazid, minoxidil Postcoronary intervention (ie, coronary dissection and perforation) Trauma Postoperative pericarditis Postmyocardial infarction (free wall ventricular rupture, Dressler syndrome) Connective tissue diseases - Systemic lupus erythematosus, rheumatoid arthritis,

dermatomyositis Radiation therapy Iatrogenic - After sternal biopsy, transvenous pacemaker lead implantation,

pericardiocentesis, or central line insertion Uremia Idiopathic pericarditis Complication of surgery at the esophagogastric junction such as antireflux surgery Pneumopericardium (due to mechanical ventilation or gastropericardial fistula)

Back to the CaseCXR: L pleural effusion and infiltration (little

improvement), enlarged heart silhoutteECHO: Dilated IVC, RA diastolic compromise,

flattened/paradoxically septum movement (dancing), moderate pericardiac fluid collection around RA/RV anteriorly, also seen posteriorly ( largest 20 mm), smallest collection is inferiorly measuring 3-4 mm in diastole

Surgery: Pericardial window, mediastinal tube placement about 150 cc cloudy, yellow fluid, culture was sent

Back to the CaseFluid culture results (-)Viral Serologies, PCRs (-)After surgery vitals and clinical picture improved1 day later extubation, afebrile3 days later all tubes were removedTransferred to the floorAfebrile during floor course and discharged with

Cephalexin