duygu unkaracalar, md pgy-1. 2,5 y/o female with grunting
TRANSCRIPT
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