Morning Report

LU LU WATERHOUSE, MD PGY-3 JULY 11, 2012

Its the start of your ED shift

21 month old male brought in by EMS for acute respiratory distress Mild rhinorrhea and cough x 2 days Sudden episode of choking/gagging, blue lips, looking lifeless Was in with dad who was painting PMHx/PSHx: h/o albuterol use as infant during URI, but no diagnosis of asthma Craniosynostosis repair 2011 h/o UTIs Possible speech delay; no current PCP MEDS: PRN ibuprofen ALLERGIES: NKDA IMMS: vaccines up to 6mo, then parents refused FHx: Asthma in mother and several maternal relatives. Maternal

GM with h/o SVT. SHx: Lives in Utah with parents and younger sister. 1 dog.

Physical Exam
VS: Temp 36.6, HR 139, RR 40-60, BP 116/83, O2 sat 70s% on

RA, 100% on non-rebreather Weight: 11kg GEN: Upset, crying, trying to pull off medical equipment. HEENT: NC/AT, conjunctivae clear, nares clear, TMs normal, O/P clear, MMM. NECK: Supple, no stiffness. No LAD. CV: Tachycardic, regular rhythm. No murmurs or gallops. 2+ peripheral pulses. 2 sec CRT. RESP: Tachypneic with mild subcostal retractions. CTAB, good breath sounds throughout ABD: Soft, NT/ND, no masses or HSM. NEURO: Alert, PERRL, EOMI, good tone, moving all extremities SKIN: Warm, no rashes

Differential diagnosis??
21 month old male with h/o albuterol use presenting

in acute respiratory distress

Differential Diagnosis
PULM Acute asthma exacerbation (viral URI trigger) Foreign body aspiration ID Bronchiolitis/viral pneumonia Bacterial pneumonia NEURO Seizure CV Arrhythmia TOXIN INGESTION Hydrocarbon ingestion/aspiration Any toxin that causes metabolic acidosis

Salicylate overdose Methanol/ethylene glycol (anti-freeze, windshield wiper fluid, household solvents and cleaners) Metformin Carbon monoxide Cyanide

Any toxin that causes cellular hypoxia

Organophosphates/carbamates (old insecticides)

Patients Labs and Imaging

CBG in ED (HD#1): pH 7.31/pCO2 46/pO2 176/HCO3 23/ -3 BMP (HD#2): Na 137, K 4.9, Cl 110, CO2 15, BUN 8, Cr 0.24, gluc 88, Ca 9.1 CBC (HD#3): WBC 14.1 (64N/27L8M), Hb 11.0, Hct 32.6, Plt 277

HD #1

HD #2

Hydrocarbon Ingestion/Aspiration
Epidemiology: 1-2% non-pharmacologic exposures in children <6yo. Inhalant abuse and suicide attempts causes toxicity in adolescents. Classes of hydrocarbons: Aromatic: solvents, glues, nail polishes, paints and paint removers Aliphatic: petroleum distillates, i.e. gasoline, kerosene, naphtha (furniture polishes, lamp oil, lighter fluid) Halogenated: solvents, propellants, refrigerants, flame retardants Terpene: turpentine, pine oil Types of toxicity: Low toxicity (unless gross aspiration): i.e. asphalt, tars, mineral oil, petroleum jelly, motor oil, axle grease Aspiration hazard:

Inversely related to viscosity and surface tension, directly related to volatility Effects usually limited to direct pulmonary damage -> inflammation i.e. turpentine, gasoline, kerosene, mineral spirits (paint thinner), lighter fluids
Usually halogenated and aromatic hydrocarbons Readily absorbed through GI/Resp systems -> blood/CV and CNS effects

Systemic toxicity:

Clinical Manifestations
Initial presentation: from asymptomatic to respiratory distress/hypoxia ->

respiratory failure Vital signs:

May present with fever. O2 sats may be decreased.

Respiratory: Symptoms usually within 30min, but may be 12-24hrs delayed Coughing, gagging, vomiting, tachypnea, dyspnea, wheezing, cyanosis Complications: asphyxia, necrotizing chemical pneumonitis, hemorrhagic pulmonary edema CNS: Rapid onset of symptoms. Hypoxia may cause secondary CNS toxicity Headache, somnolence, blurred vision, ataxia, dizziness, seizures, coma CV: Dysrrhythmias and myocardial dysfunction GI: Irritation/edema, mucosal ulceration, hematemesis, possible transaminitis/hepatic necrosis RENAL: Renal tubular necrosis HEME: Leukocytosis (may persist for 1 wk) Rare complications: hemolysis, hemoglobinuria, consumptive coagulopathy

Initial Management
Mild/mod respiratory symptoms: - NPO, CXR immediately, O2 supplementation - At risk for chemical pneumonitis -> respiratory failure Severe respiratory distress or significant altered mental status: - O2 supplementation & Albuterol - Endotracheal intubation - Immediate CXR

Asymptomatic: - NPO, CXR w/in 4-6hrs - Observe closely

Seizures: - IV benzodiazepine (Lorazepam 0.1mg/kg) - Protect airway

DECONTAMINATION: Health care providers should don appropriate protective equipment Skin/Eyes copious water irrigation, remove contaminated clothes GI do not induce vomiting due to risk of aspiration no activated charcoal (may cause vomiting, doesnt bind well) unless co-ingested toxic substance that does bind well NG lavage only if w/in 1hr of ingestion and risk of systemic toxicity from GI absorption greater than risk of aspiration from lavage

Respiratory Management
Bronchospasms: selective -2 agonists Avoid epinephrine and isoproterenol -> fatal ventricular dysrrhythmia ETT intubation with conventional ventilator ECMO and high frequency ventilation may be helpful if hypoxemia is unresponsive to conventional vent Children are able to regenerate new lung tissue after injury Corticosteroids are not helpful and may be harmful Pneumonitis not routinely treated with antibiotics unless signs of

secondary infection:

Recurrence of fever after first 48hrs Increasing infiltrate on CXR Leukocytosis after first 48hrs Sputum or tracheal aspirate positive for bacteria

Pneumatoceles usually resolve spontaneously so no specific

treatment is needed

Prognosis
Depends on specific agent involved, volume of

ingestion/aspiration, and adequacy of medical care.

Typical clinical course averages 2-5 days

Most children survive without complications or

sequelae, but some can progress to respiratory failure and death

Mild CNS depression after ingestion seldom has serious morbidity if there is no respiratory involvement Small airways are at greatest risk for long-term injury