A mother brings her 2-month-old infant to the emergency department because of profuse vomiting and severe diarrhea. The infant is dehydrated, has a cardiac arrhythmia, appears to have ambiguous genitalia, and is in distress.
This presentation suggests a diagnosis of:
Correct Answer C: Congenital adrenal hyperplasia is a family of diseases caused by an inherited deficiency of any of the enzymes necessary for the biosynthesis of cortisol. In patients with the salt-losing variant, symptoms begin shortly after birth with failure to regain birth weight, progressive weight loss, and dehydration.
Vomiting is prominent, and anorexia is also present. Disturbances in cardiac rate and rhythm may occur, along with cyanosis and dyspnea. In the male, various degrees of hypospadias may be seen, with or without a bifid scrotum or cryptorchidism.
A 3-year-old with a history of asthma is brought to the Emergency Department in acute respiratory distress. His mother relates that she stopped his twice daily sodium cromoglycate one week ago. Physical examination reveals a distressed child with a harsh cough. On auscultation of the chest, there are areas of reduced air entry and diffuse expiratory wheezes.
Which one of the following is the most appropriate initial management?
Correct Answer E: The most severe form of asthma is called status asthmaticus. In this condition, the lungs are no longer able to provide the body with adequate oxygen or adequately remove carbon dioxide. Without oxygen, many organs begin to malfunction. The buildup of carbon dioxide leads to acidosis, an acidic state of the blood that affects the function of almost every organ. Blood pressure may fall to low levels. The airways are so narrowed that it is difficult to move air in and out of the lungs.
Status asthmaticus requires intubation and ventilator support as well as maximum doses of several medications such as salbutamol or albuterol (choice E). Which are a short-acting Beta2-adrenergic receptor agonists used for the relief of bronchospasm.
→ Aerosolized ipratropium bromide by nebulization (choice A) Ipratropium is not first-line therapy and is added to short acting beta-agonists in severe exacerbation. It is not given as initial medication.
→ Aerosolized sodium cromoglycate by nebulization (choice B) would not very effective in acute asthma exacerbation. Short acting beta agonists are always initial therapy in acute asthma attacks.
→ Aerosolized budesonide (choice C) is used for maintenance and prophylactic treatment of asthma, it is not appropriate for acute asthma attack cases. When 3 doses of short acting beta agonists do not relieve the symptoms, oral prednisone or intraveneous methylprednisolone can be given.
→ Subcutaneous epinephrine (choice D) has no proven advantage over aerosol therapy with selective beta2-agents. It may, however, be considered in severe bronchoconstriction precipitated by an allergen or in situations where aerosolized selective beta-2-agonists are not available within reasonable time.
An 11-year-old boy presents with acute asthma exacerbation. His arterial blood gas in the ED shows a normal pCO2 value.
What does this finding suggest?
Correct Answer C: In cases of mild asthma the patient usually is able to maintain normal arterial blood oxygen levels. When hyperventilation occurs the CO2 value decreases. In severe disease the patient can no longer maintain the adequate alveolar ventilation and the CO2 levels start to rise.
Thus when a patient has a normal or elevated CO2 level during an acute asthmatic episode, it is a sign of severe disease, since it is evidence that the body's need to eliminate CO2 is not being met, because of a decrease in alveolar ventilation.
Which one of the following is true concerning control of mild persistent asthma in the pediatric population?
Correct Answer E: Initial medications for the control of mild persistent asthma in children should include an anti-inflammatory agent, such as glucocorticoids or cromolyn. Cromolyn may be used safely in any pediatric age group, including infants.
→ Ipatropium bromide is useful in the treatment of COPD but has very limited use for asthma.
→ Inhaled beta-adrenergic agents should be used every 4 hours if needed. Overuse of these agents has been associated with an increased mortality rate.
A 6-year-old male is brought in for evaluation by his mother, who is concerned that he may have asthma. She reports that he coughs about 3 days out of the week and has a nighttime cough approximately 1 night per week. There is a family history of eczema and allergic rhinitis.
Which one of the following would be the preferred initial treatment for this patient?
Correct Answer B: Treatment is based on asthma classification. This child meets the criteria for mild persistent asthma: daytime symptoms of asthma more than twice weekly but less then once daily, and nocturnal symptoms of asthma 3-4 times per month, peak expiratory flow (PEF) or FEV1 ≥ 80% of predicted, and a PEF variability of 20%-30%.
Asthma controller medications are recommended for all patients with persistent asthma, and the preferred long-term controller treatment in mild persistent asthma is a low-dose inhaled corticosteroid. Cromolyn, leukotriene modifiers, nedrocromil, and sustained-release theophylline are alternatives, but are not preferred initial agents. Quick. acting, quick-relief agents such as short-acting beta-agonists are appropriate for prompt reversal of acute airflow obstruction.
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