Which of the following patients with congenital heart disease would be expected to exhibit cyanosis?
Correct Answer C: Truncus arteriosus (choice C) is a rare form of congenital heart disease which presents with moderate cyanosis at birth due to the fact that there is complete mixing of systemic and pulmonary venous blood.
→ Although tetralogy of Fallot (choice A) is usually also associated with cyanosis, there must be at least 50 g/L of deoxygenated hemoglobin present in order for cyanosis to be present. Therefore, in severely anemic states, cyanosis may not be present. Of note, cyanosis cannot be detected by observation in patients with severe anemia (Hb < 50 g/L).
→ Coarctation of the aorta (choice B) is not typically a cyanotic lesion. Femoral pulses will be weak or absent with upper extremity hypertension.
→ VSD (choice D) is the most common congenital heart disease. A severe lesion may result in congestive heart failure but without cyanosis.
→ ASD (choice E) is not a cyanotic lesion, although high flow or secundum lesions may require SBE prophylaxis.
A 3-year-old boy comes to the ED wheezing. It was sudden in onset. On chest x-ray you notice hyperinflation in the right part of the chest.
What is the most appropriate next step?
Correct Answer B:
Wheezing is a symptom as well as a physical finding. Wheezing occurs as a result of airway narrowing. Asthma is the most classic cause of wheezing, but wheezing may be part of COPD, heart failure exacerbation (cardiac asthma), bronchiolitis in children, anaphylaxis, toxic inhalation, foreign body aspiration, tracheomalacia, or vocal cord dysfunction.
A pulse oximetry reading and a chest x-ray should be taken. Segmental or subsegmental atelectasis or infiltrate suggests an obstructing endobronchial lesion. Radio-opacity in the airways or focal areas of hyperinflation suggests a foreign body. The object should be removed immediately via bronchoscopy.
A 2-year-old child, who was previously well, presents with a sudden onset of brassy cough, respiratory distress and wheeze. Examination reveals that he is afebrile with diminished air entry and wheezing on the right side.
Which one of the following is the most likely diagnosis?
Correct Answer D:
Children, especially those aged 1-3 years, are at risk for foreign body aspiration because of their tendency to put everything in their mouths and because of the way they chew. A foreign body in the trachea may result in a brassy cough, with or without loss of voice, and bi-directional stridor (during inspiration and expiration). Complete airway obstruction and asphyxia can result from a large object lodged in the trachea or larynx. Early signs of respiratory failure include respiratory rate outside the normal range for the patient's age (either too fast or too slow), tachycardia progressing to bradycardia, and initial increased work of breathing, which can progress to decreased and inadequate work of breathing. Cyanosis, stridor, and altered level of consciousness are ominous signs, and may predict impending respiratory arrest.
Predictive signs of bronchial foreign body aspiration (FBA) include stridor, asphyxia, radio-opaque object seen on chest x-ray, a history of foreign body aspiration associated with unilaterally decreased breath sounds, localized wheezing, obstructive hyper-inflation, or atelectasis.
FBA is a very serious, often life-threatening, condition. 3% of all unintentional deaths among children (<15 years old) are secondary to the inhalation/ingestion of food or objects. In fact, 5% of all FBA deaths occur in this age group. Of children younger than 15 years, toddlers seem to be the most vulnerable for foreign body aspiration (77% of deaths).
An 18-month-old boy is brought to the emergency room by his parents. He has been wheezing since this morning. He had a runny nose and fever 2 days prior to this visit, which have resolved. There is no family history of asthma. On exam, the child appears active and in no acute distress. You notice nasal flaring and there is wheezing in the right lung fields. A chest x-ray reveals hyperinflation of the right lung and there is no infiltrate.
The most appropriate next step in management is:
This toddler has a foreign body aspiration, as suggested by his lung and CXR findings. A foreign body should always be considered in the differential of a wheezing toddler. Management includes removal under direct visualization by rigid bronchoscopy.
A. Beta agonist therapy is appropriate for the management of asthma.
B. Steroid therapy is used for the management of asthma exacerbation and is not useful in the treatment of a foreign body aspiration.
C. Chest tube placement is indicated for lung collapse, as opposed to hyperinflation.
E. Racemic epinephrine is used in the treatment of laryngotracheobronchitis (croup) and is indicated in patients with stridor at rest.
A term newborn to a mother who had no prenatal care or screening tests, a few hours after birth develops respiratory difficulty, tachycardia, and temperature instability.
What is the most likely cause?
Group B streptococcal (GBS) septicemia is a severe bacterial infection that affects newborn infants. It is caused by the bacteria Streptococcus agalactiae. This bacteria is commonly found in the human gastrointestinal, reproductive, and urinary tracts. If the bacteria travels from the mother's bloodstream through the placenta the infant can become infected. Premature rupture of membranes without other complications for more than 24 hours before delivery is associated with a 1% increase in the incidence of neonatal sepsis. However, when chorioamnionitis accompanies the rupture of membranes, the incidence of neonatal infection is quadrupled.
The infant may also become infected after delivery. The disease may be seen from birth to 6 days of life (generally in the first 24 hours) or in children age 7 days to 3 months. Most cases occur in babies around 1 month old. Group B streptococcus was once responsible for about 75% of sepsis infections in infants. However, the rate of this condition has dropped since methods to screen and treat pregnant women at risk have been established.
Symptoms in the infant may include: anxiety or stress, blue appearance (cyanosis), breathing difficulties such as: grunting, flaring of the nostrils, rapid breathing, short periods without breathing, coma, irregular heart rate - may be fast or extremely slow, irregular heartbeat, lethargy, poor feeding, shock, and unstable body temperature (low or high).
Diagnosis involves blood cultures, blood gases, complete blood count, CSF culture, urine culture and X-ray of the chest. Treatment is with antibiotics, IV fluids and oxygen.
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