ABSTRACT. A 3-month-old infant of 33 weeks' gestation was hospitalized with pneumonia caused by Bordetella pertussis. Respiratory insufficiency worsened, and on hospital day 3, there was severe pulmonary dysfunction (arterial oxygen pressure/fraction of inspired oxygen ratio: 120), extreme leukocytosis (white blood cell count 104 000/mm 3 ), and severe pulmonary hypertension as assessed by 2-dimensional echocardiogram. A double volume exchange transfusion was performed to reduce the leukocyte mass. Oxygenation began to improve during the exchange and continued to improve over the ensuing 31 hours (arterial oxygen pressure/fraction of inspired oxygen ratio: 280). The white blood cell count fell dramatically after the exchange, and the rate of rise was slower after exchange therapy compared with preexchange. T he constellation of bronchopneumonia, extreme leukocytosis, refractory hypoxemia, and pulmonary hypertension (PHT) is well described in severe Bordetella pertussis infection in infants. 1,2 The onset of refractory hypoxemia typically is rapid 3,4 and responds poorly to advanced ventilation maneuvers, including high-frequency oscillatory ventilation, inhaled nitric oxide, and extracorporeal life support (ECLS). 5,6 The mechanism of hypoxemia and pulmonary hypertension in this setting is undetermined; however, several lines of evidence support leukocyte thrombi as the cause. White blood cell (WBC) counts Ͼ100 000 in the setting of B pertussis pneumonia are associated with increased mortality. 7,8 A leukocyte thrombus in a pulmonary venule has been reported in a fatal case of B pertussis pneumonia. 3 Finally, respiratory distress has been described in adults and children with hyperleukocytosis secondary to leukemia. 9,10 In the last setting, respiratory distress has resolved after the application of techniques to reduce the leukocyte mass, including leukopheresis and exchange transfusion. We postulated that the application of a similar strategy to reduce leukocyte mass in the setting of B pertussis pneumonia, hypoxemia, and PHT may prevent additional thrombi formation and allow resolution of preexisting thrombi. We report the first use of a double volume exchange transfusion as a therapy for B pertussis pneumonia with PHT and hypoxemia and describe the improvements in oxygenation temporally associated with that therapy. CASE REPORTSA 3-month-old, 5-kg, white girl had been seen 3 times in the 16 days before admission for cough and rhinitis. She was prescribed albuterol and a 2-day course of prednisone when she first became ill, and nebulized albuterol was prescribed at 2 subsequent visits, all with minimal improvement. The patient was seen by her primary care physician and admitted to a local hospital with mild respiratory distress. Her physical examination was remarkable for temperature 101.1°F, heart rate 176 beats/min, respiratory rate 60 breaths/min, and oxygen saturation 96% with the fraction of inspired oxygen (Fio 2 ) 0.27. Lung examination was significant for rales in all fields with a congested, "hackin...
Asthma is the most common chronic disease affecting children. Studies have demonstrated improvements in asthma control when care is delivered by specialists compared with generalists. We postulated that specialist care delivered by telemedicine would result in similar improvements in control of symptoms and quality of life as compared with face-to-face encounters with specialists. Seventeen patients with persistent asthma, who were cared for by pediatricians in a rural school-based health clinic, were treated over a 6-month period in an asthma specialty program. Patients had face-to-face encounters at week zero, and then telemedicine follow-up visits at weeks 4, 12, and 24. Patients maintained a symptom diary and reliever medication use log. Spirometry and patient and caregiver quality-of-life questionnaires were completed at each visit. Mean number of symptom free days increased 83% from 2.35 days at week 0 to 4.31 days at week 24 (p < 0.05). There was a 44% reduction in mean symptom scores, from 2.32 at week 0 to 1.31 at week 24 (p < 0.001). Nine patients reported having 7 symptom-free days or 7 days of symptom scores of zero in the preceding seven days at week 24 compared with one patient at week 0 (p < 0.002). FEV(1) increased by > or = 12% in seven patients during the study period. Significant improvements in quality of life were reported by patients at week 4 (p < 0.02) and week 24 (p < 0.01), and by caregivers at week 24 (p < 0.002). Specialty asthma care delivered via telemedicine resulted in improvements in asthma symptom control and quality of life similar to improvements reported in face-to-face encounters provided by specialists.
A 5-year-old child who weighed 17.5 kg received 50 mg of clonidine. The amount ingested was confirmed by analysis of the suspension administered (clonidine HCl 9.78 mg/mL). To our knowledge, this represents the largest ingestion in a child and the largest ingestion on a milligram per kilogram basis in the medical literature. The child's initial presentation included hyperventilation, an unusual feature of clonidine toxicity. The child was discharged without sequela 42 hours after admission. A serum concentration of clonidine 17 hours postingestion was 64 ng/mL, the highest reported to date in a pediatric patient. The intoxication was traced to a pharmacy compounding error in which milligrams were substituted for micrograms. Increased prescribing of clonidine in young children coupled with the requirement to compound clonidine in a suspension and the narrow therapeutic index suggests that the frequency of severe ingestions in children will increase in the future.
BackgroundUnrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in the emergency department. Recent studies have demonstrated that point-of-care ultrasound (POCUS) may be a useful adjunct for confirming endotracheal tube placement; however, the amount of practice required to become proficient at this technique is unclear. The purpose of this study is to determine the amount of practice required by emergency physicians to become proficient at interpreting ultrasound video clips of esophageal and endotracheal intubations.MethodsEmergency physicians and emergency medicine residents completed a baseline interpretation test followed by a 10 min online tutorial. They then interpreted POCUS clips of esophageal and endotracheal intubations in a randomly selected order. If an incorrect response was provided, the participant completed another practice session with feedback. This process continued until they correctly interpreted ten consecutive ultrasound clips. Descriptive statistics were used to summarize the data.ResultsOf the 87 eligible physicians, 66 (75.9 %) completed the study. The mean score on the baseline test was 42.9 % (SD 32.7 %). After the tutorial, 90.9 % (60/66) of the participants achieved proficiency after one practice attempt and 100 % achieved proficiency after two practice attempts. Six intubation ultrasound clips were misinterpreted, for a total error rate of 0.9 % (6/684). Overall, the participants had a sensitivity of 98.3 % (95 % CI 96.3–99.4 %) and specificity of 100 % (95 % CI 98.9–100 %) for detecting correct tube location. Scans were interpreted within an average of 4 s (SD 2.9 s) of the intubation.ConclusionsAfter a brief online tutorial and only two practice attempts, emergency physicians were able to quickly and accurately interpret ultrasound intubation clips of esophageal and endotracheal intubations.Electronic supplementary materialThe online version of this article (doi:10.1186/s13089-015-0031-7) contains supplementary material, which is available to authorized users.
ObjectivesThis study sought to establish by expert review a consensus‐based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program.MethodsAn expert panel of 21 point‐of‐care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5‐point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed.ResultsOf the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded.ConclusionsBy expert opinion‐based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.
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