Pediatric Examination and Board Review (19 page)

11.
(B)
Most parainfluenza virus infections are mild with episodes of laryngotracheobronchitis lasting for 3-4 days, and treatment is largely symptomatic. Marked improvement in the duration of airway obstruction has been seen with the use of corticosteroids. Parenteral dexamethasone in a dose not exceeding 0.3 mg/kg has been recommended for severe airway obstruction. A single dose of 0.6 mg/kg may be given intramuscularly as an adjunctive therapy in severe croup. Oral dexamethasone in doses of 0.15-0.6 mg/kg lessens the severity, duration of symptoms, and need for hospitalization in patients with less severe croup. Although for many years cold mist has been recommended to treat croup, there is little evidence that this intervention is beneficial.

12.
(A)
Most cases of presumed viral croup can be managed as outpatients. Hospitalization is reserved for those few that are severely ill.

13.
(A)
Once a child has received racemic epinephrine, it is important to observe for a period of no less than 6 hours because there may be a rebound increase in airway obstruction and progressive symptoms during this time period.

14.
(C)
Should symptoms of croup progress to airway obstruction, there will usually be a classic series of signs demonstrated by the patient. Initially, patients with upper airway disease (extrathoracic symptoms) present with inspiratory stridor. As the extrathoracic airway obstruction progresses, both inspiratory and expiratory stridor develop. Finally as the airway narrows critically, stridor becomes quite muffled until there is little air movement at all and no sound. When patients develop biphasic stridor, respiratory failure can be anticipated and the patient should be placed in a monitored setting and aggressively treated, perhaps even intubated.

Physiologically, the airway is divided into 2 portions: an extrathoracic and an intrathoracic portion. Symptoms of airway disease depend on the location of the pathology in the airway. Epiglottitis and croup represent diseases of the extrathoracic airway. Under these conditions, airway symptoms begin on inspiration because the extrathoracic airway narrows on inhalation, whereas the intrathoracic airway will expand with the negative intrathoracic pressure generated with inhalation. Intrathoracic airway pathology, such as a vascular ring or a mediastinal tumor, presents with symptoms on exhalation. That sound heard on exhalation as a result of airway disease is frequently misconstrued as wheezing and treated as asthma when, in fact, the clinician is dealing with expiratory stridor.

Disease that compromises the intrathoracic airway causes expiratory stridor first because the intrathoracic airway is reduced in caliber during exhalation. As airway caliber is reduced to a critical level, regardless of the location, stridor will be present on inspiration and expiration (biphasic stridor) and heralds impending respiratory failure.

S
UGGESTED
R
EADING

Cohen LF. Stridor and upper airway obstruction in children.
Pediatr Rev.
2000;21:4-5.

Gallagher PG, Myer CM III. An approach to the diagnosis and treatment of membranous laryngotracheo-bronchitis in infants and children.
Pediatr Emerg Med.
1991;7(6):337-334.

Jenkins IA, Saunders M. Infections of the airway.
Paediatr Anaesth
2009;19(suppl 1):118-130.

Leipzig B, Oski FA, Cummings CW, et al. A prospective randomized study to determine the efficacy of steroids in treatment of croup.
J Pediatr.
1979;94(2):194-196.

Malhotra A, Krilov LR. Viral croup.
Pediatr Rev.
2001;22:5-12.

CASE 9: A 6-YEAR-OLD BOY FOUND AT THE BOTTOM OF THE NEIGHBOR’S POOL

A 6-year-old boy is brought to the emergency department by emergency medical services (EMS). He was found at the bottom of his neighbor’s swimming pool and rescued. At the scene, he was without vital signs initially. After 5 minutes of basic life support efforts, he had a cardiac rhythm and a pulse, but he was making no respiratory effort. The child was intubated and placed in a cervical collar.

On physical examination the child is unresponsive. His vital signs are blood pressure 110/56, pulse 100, respiratory rate while bagging 22, temperature 34.5°C, and oxygen saturation 100%. Auscultation of the chest reveals wheezing in the right hemithorax and coarse breath sounds throughout. The cardiac rhythm is sinus and there are no murmurs. The only other part of the physical examination that is abnormal is the neurologic examination. The child remains unresponsive to pain or voice. Pupils are 4 mm bilaterally and are very sluggish in response to light. The muscle tone is generally reduced and there is no rectal tone.

SELECT THE ONE BEST ANSWER

1.
The condition of this child dictates the need for the following

(A) obtaining an AP chest film

(B) obtaining a blood sample for toxicology

(C) obtaining imaging studies of the head and cervical spine

(D) obtaining left and right lateral decubitus chest films

(E) obtaining imaging of the abdomen and pelvis

2.
The clinical scenario that best predicts poor outcome in drowning is

(A) cardiopulmonary resuscitation (CPR) required at the scene of the accident

(B) CPR required in the emergency department

(C) failure to achieve spontaneous cardiac rhythm for 25 minutes

(D) submersion time longer than 5 minutes

(E) Glasgow Coma Scale score of 10 in the emergency department

3.
The clinical scenario that best predicts good outcome in drowning is

(A) core temperature on arrival in the emergency department of less than 32°C

(B) return of spontaneous circulation in the emergency department

(C) responsive pupils in the emergency department

(D) continuing or resuming circulation at the accident scene

(E) a Glasgow Coma Scale score of 4 in the emergency department

4.
Which of the following is the most common cause of morbidity and mortality in drowning?

(A) hypoxic encephalopathy

(B) acute hypoxic respiratory failure

(C) renal failure

(D) acute hyponatremia from water absorption

(E) B and C

5.
Which of the following statements is true?

(A) saltwater drowning is more common than drowning in fresh water

(B) the lung injury that occurs in a freshwater drowning is more severe than the lung injury that occurs in salt water

(C) the clinical features of saltwater and freshwater drowning are more alike than they are different

(D) drowning results in the aspiration of large volumes of water into the tracheobronchial tree and lungs, irrespective of the type of water

(E) none of the above

6.
The frequency of drowning in the United States is best described as

(A) an uncommon cause of death

(B) the second most common cause of pediatric death in many states

(C) more likely in girls irrespective of age

(D) more likely in boys younger than the age of 6, but it is of equal magnitude between the genders in older children

(E) most common in adolescent girls

7.
The most important intervention that prevents accidental pool drowning is

(A) swimming lessons

(B) flotation devices

(C) fencing surrounding a pool

(D) pool covers

(E) alarms

8.
On the second hospital day, the child’s examination was consistent with brain death. This diagnosis would not be possible to make by clinical examination if

(A) the child’s temperature is 35°C

(B) the child’s temperature is 36°C

(C) the patient’s phenobarbital level is 10 mg/dL or more

(D) the patient has a C1-2 fracture

(E) the patient has an L4-5 fracture

9.
The definition of brain death in children requires that the child be

(A) older than 7 days of age and term at birth

(B) older than 6 months old, irrespective of gestational age

(C) older than 1 year of age, irrespective of gestational age

(D) older than 2 years of age, irrespective of gestational age

(E) older than 60 weeks’ postconceptual age

10.
Confirmatory tests for brain death include all of the following except

(A) brain nuclear blood flow study

(B) MRI of the brain

(C) cerebral angiogram

(D) EEG

(E) A and C

11.
Which of the following may be present and still have the patient meet brain death criteria as of 2004, according to the American Academy of Pediatrics guidelines?

(A) spinal reflexes

(B) corneal reflexes