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CASE PRESENTATION

CASE PRESENTATION. Duygu Unkaracalar, MD PGY-1. 2,5 y/o female with grunting. HISTORY. HISTORY. 1 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

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CASE PRESENTATION

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  1. CASE PRESENTATION Duygu Unkaracalar, MD PGY-1

  2. 2,5 y/o female with grunting

  3. HISTORY

  4. HISTORY • 1 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 cough • 2 days ago PMD visit: wheezing (+), b/lotitis media Prednisolone, Albuterol, Azithromycin no improvement • Motrin was given 1 hour prior to the ER visit • Difficulty breathing, grunting started about 1/2 hour ago, no PO, BM, vomiting or urine output today • Sick contact (+) father had flu-like symptoms last week • No travel, no pets or smoking

  5. HISTORY • Birth hx: FT, NSVD, no NICU • PMH: Intermittent asthma ( x2 attacks/year, no hosp or ER visits), no surgeries Meds: Albuterol PRN • UTD, no flu vaccine • NKDA • FH: non-contributory

  6. PE

  7. PE • General: Pt was in respiratory distress, grunting, perioral cyanosis, GCS:15 • Vitals: RR: 56/min, HR: 143/min, sO2: 86%(on RA), T: 98,4 F, BP: 116/77 mm-Hg • HEENT:Perioral cyanosis, b/lTms 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/r • Abd: Soft, (+) BS, NTND, no HSM • Ext: Warm, cap refill<2 sec, b/l good pulses • Neuro: Oriented x3, CNII-XII wnl, no lateralitazions, no babinski, b/l DTRs wnl, no neck stiffness

  8. Work-up • CBCWBC: 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: 0.6/0.4 • CRP: 8.4 • ABGpH: 7.35, pCO2: 44, HCO3: 19, BE: -2.2, pO2: 58, sO2: 88% • Flu A/B: (-), RSV: (-) • Blood Culture • CXR

  9. Differential Diagnosis?

  10. Differential Diagnosis • Respiratory: 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 Failure • GI: Liver Failure, Hypoalbuminemia, Pancreatitis • Rheumotology: SLE, JRA

  11. 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

  12. PICU Course • BIPAP 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 pending • Respiratory failure Intubated • Acute renal failure ( 59/1, 37/0.7)Hemodialysis x2 • T: 37.6-39.8 • Subsequent CXRsworsen R pleural effusion R chest tube • Repeat CBCWBC: 59, Hb: 10.4, Htc: 29.6, Plt: 225 (78%PMNL, 17%L, 5%M) • Ctx, Vancomycin, Famotidine, Alb neb, CS, Tylenol, TPN • Blood cx: (-), H1N1, Flu A/B PCRs (-)

  13. Pleural Effusion • Collection of at least 10-20 mL of fluid in the pleural space • Normally 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 neutrophils • Infection is the most common cause of pleural effusion, 2. Congenital heart disease (CHD), 3.Malignancy • Classified as transudates and exudates

  14. Pleural Effusion Exudate Transudate • Cloudy • pH < 7.2 • PP/SP > 0.5 or prt >3 g/dl • P 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 • Clear • pH=7.45 or =serum pH • PP/SP<0.5 or prt < 3 g/dl • P LDH/S LDH < 0.6 • P Glu/S Glu > 0.5 • Congestive heart failure, hypoalbuminemia, nephrosis, hepatic cirrhosis, and iatrogenic causes (eg, misplaced central line, complication of ventriculopleural shunt)

  15. Pleural Effusion-LAB • CBC with diff, CRP, Blood culture, serum LDH, CMP • Serology Mycoplasma, Legionella Ag, viral • Pleural 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 • ppd • Coag tests

  16. Definitions • Parapneumonic effusion Pneumonia with evidence of effusion • Uncomplicated (or simple) free flowing pleural fluid • Complicated loculated pleural fluid • Empyema Pus in pleural space

  17. Signs & Symptoms • Fever • Cough • Dyspnea • Cyanosis • Lethargy • Pleuritic chest pain • Abdominal pain • Vomiting • Decreased breath sounds • Decreased chest expansion • Crackles • Friction rub • Dullness on percussion • Tracheal shift

  18. Etiology • Pneumonia(viral,bacterial,tuberculosis, mycotic) • Lung abscess • Trauma • Postoperative • Extension of subphrenic abscess • Generalized sepsis

  19. Etiology • The 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 group • Tuberculosis-worldwide • Anaerobic infections -secondary to aspiration • Fungal or mycobacterial infections – immunosuppressed

  20. AP CXR Lateral CXR R Decubitus Loculated pleural effusion-USG B/L Pleural effusion-CT

  21. Treatment • Antibiotics (10-14 days of intravenous antibiotics) Sulbaktam-Ampicillin, 2nd generation cephalosporins (e.gCefuroxime), 3rd generation cephalosporins (e.gCeftriaxone), Vancomycin, Clindamycin 1-3 wks PO antibiotics-according to clinical picture and respond • Diagnostic 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 scan • positive Gram stain or culture • pH less than 7.20 • pleural fluid consists of pus • Multiloculated effusions (tPA- via chest tube, surgery)

  22. Prognosis • Complications are rare and prognosis is quite good in pediatric population • Radiographic 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

  23. Follow-up • Afebrile and improving clinicallythe IV drugs can be switched to PO medications for 1-3 weeks • Children should be examined within 2-4 weeks after discharge, depending on the patient's clinical status • Some experts recommend serial chest radiography to ensure clearing • Some perform CT scanning after the plain radiographs clear

  24. Back to the Case • x3/day fever spikes T: 39.9 • Urine Strep. Pneumonia Ag: (+) • Repeat Blood cultures (-) • Pleural effusion culture(-) • ppd(-) • Repeat CXRsimprovement • 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:9-1823-24 mm-Hg) • BiPAP not tolerated • Intubated again

  25. PE Findings • Alert, in respiratory distress • HR: 188/min, RR:55/min, sO2: 88%(2L NC), T:38.5, BP: 56/35 mm-Hg, CVP: 24 mm-Hg • Lungs: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 SM • Ext:Cap refill 3 sec, b/l weak pulses, edema

  26. What is the diagnosis? • Management?

  27. Pericardial Effusion Cardiac Tamponade Cardiogenic Shock

  28. Pericardial Effusion • Pericardial space contains approximately 20 mL of fluid • Most 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 years • Symptoms are often nonspecific- fever, respiratory distress, and tachycardia, chest pain • Most patients have a preceding or concurrent infection: • Pneumonia • Meningitis • Acute osteomyelitis • Acute arthritis • Soft tissue infections

  29. Cardiac Tamponade • Pericardial fluid accumulates rapidly enough or in sufficient volume to impair diastolic filling • Complications: Pulmonary edema, shock, death • During tamponade, all 4 cardiac chambers compete for space within the pericardium; • Increased systemic venous and atrial pressure- HM, edema, JVD, increased CVP • Increase pulmonary venous pressure- pulmonary edema, hypoxia, respiratory distress

  30. Cardiac Tamponade • Tachycardia • Tachypnea • Hepatomegaly • Diminished heart sounds • JVD • Hypotension • Increase CVP • Delayed cap refill • Weak 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

  31. 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)

  32. Back to the Case • CXR: L pleural effusion and infiltration (little improvement), enlarged heart silhoutte • ECHO: 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

  33. Back to the Case • Fluid culture results (-) • Viral Serologies, PCRs (-) • After surgery vitals and clinical picture improved • 1 day later extubation, afebrile • 3 days later all tubes were removed • Transferred to the floor • Afebrile during floor course and discharged with Cephalexin

  34. A 16 m/o African-American boy presents to ED with 3 days of fever and cough. Has not been hungry but continues to drink well. His fever has persisted despite antipyretics and is now 39.0. No other symptoms, sick contacts or travel history. On PE child looks toxic but is well hydrated. HR:140 RR: 52 Sat: 82% (RA), the only significant finding on exam is markedly decreased breath sounds on the Right hemithorax. No HSM or adenopathy noted. CXR reveals an opacified Right hemithorax with slight mediastinal shift to the Left. What is the next diagnostic procedure indicated?A) Throat CultureB) Review of the Blood SmearC) US of the Right HemithoraxD) Nasopharyngeal aspirate for viral screen

  35. A 16 m/o African-American boy presents to ED with 3 days of fever and cough. Has not been hungry but continues to drink well. His fever has persisted despite antipyretics and is now 39.0. No other symptoms, sick contacts or travel history. On PE child looks toxic but is well hydrated. HR:140 RR: 52 Sat: 82% (RA), the only significant finding on exam is markedly decreased breath sounds on the Right hemithorax. No HSM or adenopathy noted. CXR reveals an opacified Right hemithorax with slight mediastinal shift to the Left. What is the next diagnostic procedure indicated?A) Throat CultureB) Review of the Blood SmearC) US of the Right HemithoraxD) Nasopharyngeal aspirate for viral screen

  36. What is the appropriate first therapeutic intervention?A) O2 supplementationB) ABGC) Thoracostomy tube placementD) Bronchoscopy

  37. What is the appropriate first therapeutic intervention?A) O2 supplementationB) ABGC) Thoracostomy tube placementD) Bronchoscopy

  38. THANK YOU

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