Pediatric Examination and Board Review (20 page)

(C) doll’s eyes (oculocephalics)

(D) pupillary response to light

(E) respiratory effort

12.
Which is true about the original Harvard description of “brain death”? (Note that the terminology actually used by the Harvard group was “irreversible coma” as opposed to “brain death.”)

(A) the recommendations of the original Harvard group specified special criteria in children younger than 2 years of age

(B) the recommendations of the original Harvard group did not address brain death in children

(C) the “Harvard Criteria” required that confirmatory tests be used in all children younger than 1 year of age before declaration of death

(D) the “Harvard Criteria” for brain death required 2 EEGs to confirm brain death for children but made no such requirement for adults

(E) the “Harvard Criteria” for brain death required confirmatory tests be used in all patients regardless of age

13.
The diagnosis of brain death in children as currently described by the leading societies of neurology and pediatrics requires that

(A) confirmatory tests be used in all age children before declaration of death

(B) confirmatory tests be used in all children younger than 1 year of age before declaration of death

(C) a neurologist examine all children before the declaration of brain death

(D) the declaration of brain death can be made in all children on the first physical examination consistent with brain death

(E) B and C

14.
Which of the following children meet the definition of brain death?

(A) a 6-day-old with birth asphyxia who has an isoelectric EEG

(B) a 6-month-old infant found pulseless at home with agonal respirations, otherwise completely unresponsive

(C) a 2-year-old drowning victim with no brainstem function

(D) a 2-year-old trauma victim with no brainstem function, whose core temperature is 33°C

(E) a 16-year-old adolescent found unresponsive at a “Rave” party and brought to the emergency department intubated by EMS

15.
Which of the following children should have confirmatory diagnostic testing in radiology before declaration of brain death because the brain death physical examination is not valid?

(A) a 3-year-old after a motor vehicle accident (MVA) with concomitant thoracic spine trauma

(B) a 6-year-old after MVA with concomitant cervical spine trauma

(C) a 7-year-old after a MVA with diffuse axonal injury

(D) a 4-year-old after a MVA who has spina bifida occulta

(E) a 10-year-old without concomitant trauma

ANSWERS

1.
(C)
In this case scenario, the initial physical examination was complicated by the absence of rectal tone. Once the airway has been carefully secured and hemodynamic status stabilized, this finding should direct your initial workup to urgent imaging of the head and cervical spine. Frequently, diving accidents are followed by prolonged submersion when concomitant spinal injury is involved. As with all patients who suffer traumatic accidents, coexisting injuries need to be diligently sought. Notably, especially in the elder child who suffers a submersion event, a concomitant diving injury may also be present. It is wise to image both the head and cervical spine in a victim who is unable to communicate, particularly when the accident was not witnessed. Prehospital care providers should treat patients with a drowning injury as if concomitant cervical spine trauma is present unless it is clearly observed that the patient did not dive into the body of water from which he or she was rescued. It is unlikely to have a concomitant abdominal injury in a diving injury.

Importantly, submersion injury may be the initial presentation for a child with prolonged QT syndrome, especially if the event was not witnessed. This mandates that an ECG be performed on all submersion victims when they are normothermic and their electrolytes are normal.

2.
(C)
The ultimate determinant of the quality of a submersion victim’s recovery is the duration of hypoxic injury. The most reliable predictors of poor outcome in the pediatric population are submersion that exceeds 10 minutes in duration, resuscitation efforts to achieve spontaneous cardiac rhythm that exceed 25 minutes, and admission to a pediatric intensive care unit with a Glasgow Coma Scale score <5 (
Table 9-1
). Despite this, 8-30% of children who require CPR at the scene of a drowning accident survive neurologically intact.

Prompt prehospital intervention is crucial for the injured child with a potentially reversible process. Delay in the initiation of basic and/or advanced life support in this patient population augments the hypoxic insult. A great deal of discussion has occurred regarding the routine use of the Heimlich maneuver in the prehospital care of the drowning victim. The American Red Cross continues to dissuade delaying basic life support to perform this maneuver except in the case of a patient with an airway obstruction. The presence of water in the tracheobronchial tree does not warrant the routine performance of the Heimlich maneuver, which instead may increase the quantity of regurgitated material and hamper efforts at maintaining a patent airway. There must be no delay in instituting basic and advanced life support maneuvers for the child in full arrest after a drowning.

TABLE 9-1.
Glasgow Coma Scale

3.
(D)
The best predictors of a good neurologic outcome are the return of spontaneous circulation at the scene of the accident and never losing spontaneous circulation at all. Approximately 8-30% of children who require CPR at the scene of a drowning accident will survive neurologically intact. Much has been made of the circumstance of cold water submersion. Cold water locations are implicated in only 2% of all submersion deaths. Because of the protective effects of hypothermia on the brain and other vital organs, surviving a prolonged submersion is possible. It should be noted that the water needs to be cold enough to support ice on its surface for the protective effects of hypothermia to be seen. Water temperature must be less than 86°F (<30°C). Cool water does not offer the same protection. The child must cool quickly to rapidly decrease cerebral-oxygen consumption and be afforded protection by the cold. In spite of descriptions in the medical literature and lay press of dramatic recoveries from prolonged cold water submersions, these are rare. It is much more important to prevent the injury than to attempt to resuscitate the child who is already injured.

4.
(A)
Morbidity and mortality in drowning are largely the result of prolonged hypoxemia. Deaths that result from drowning events are largely the result of anoxic encephalopathy, that is, brain swelling, with subsequent herniation and ultimately brain death. Aspiration of water into the tracheobronchial tree causes lung injury that results in decreased lung compliance, ventilation perfusion mismatch, surfactant deactivation, and intrapulmonary shunting. These lead to a patient with continued hypoxemia, complicating the initial neurologic injury, which also largely results from hypoxemia. Prompt prehospital intervention is crucial for the injured child with a potentially reversible process. Delay in the initiation of basic and/or advanced life support in this patient population also augments the hypoxic insult. Frequently, hypoxic encephalopathy is apparent at the time of initial examination and worsens over the first 24-48 hours with progressive cerebral edema. It can be stated with reasonable certainty that for a patient who makes no improvement in the first 24-48 hours, the outcome from a drowning is almost certainly poor.

5.
(C)
Much has been made of the difference between drowning in salt water and drowning in fresh water. Because the submersion generally causes laryngospasm, it does not result in the aspiration of more than 3-4 mL/kg of water. Therefore, the distinction between saltwater drowning and freshwater drowning is not considered clinically important. Both types of drowning result in decreased lung compliance, increased ventilation-perfusion mismatch, surfactant deactivation, and increased intrapulmonary shunting. These lead to continued hypoxemia, complicating the initial injury, which also largely results from hypoxemia.

6.
(B)
Strictly speaking, drowning is defined as an immersion or submersion injury resulting in death. The term
near drowning
implies survival for more than 24 hours following immersion injury. Drowning is the third most common cause of accidental death in the United States. In some states with access to swimming pools, beaches, and lakes, drowning is the leading cause of death in children younger than 5 years of age. Submersion injury has a bimodal distribution of age. The first peak occurs in children younger than 5 years who are victims of unprotected backyard swimming pools. The second peak occurs in adolescents, who are victims of boating and/or swimming accidents in lakes and at beaches. These are frequently associated with alcohol or drugs and may be accompanied by spinal cord injury. In all age ranges, male victims outnumber female victims. For every child who is hospitalized following a submersion injury, at least 10 never seek medical attention and 8 others are evaluated in an emergency department and discharged. Among female children younger than 19 years of age, 1 in 3300 will drown; 1 in 1000 will be hospitalized following a water emergency. In male children younger than 19 years of age, 1 in 1100 will drown and 1 in 300 will require hospital stay for nonfatal submersion injury.

7.
(C)
Evidence from both epidemiologic and clinical studies suggests that the most effective means to reduce submersion injury of children should focus on prevention rather than therapy. The best method to prevent pediatric drowning is adequate supervision of a child at risk. Drowning in residential pools can be decreased substantially by the installation of complete pool fencing. This intervention has been well studied in Australia and New Zealand where pool fencing is mandated by law. To be effective, the fence must completely surround the pool with an automatic-locking gate. Should the gate be disabled or propped open, the protection of the fence is eliminated. Pool covers do not provide the same protection because they frequently collapse under the weight of a child. Swimming lessons also do not provide the same protection because a child frequently overestimates his or her ability to swim.

8.
(D)
It is imperative that the care provider identify any coexisting neurologic injury because it will change the course of therapy and the ability to perform a prognostic physical examination. Should the child have a cervical injury associated with submersion, the spinal cord insult will prevent the physician from assessing brainstem function by a careful neurologic examination. It will therefore be impossible to provide the family with an adequate description of the extent of neurologic insult without confirmatory testing, particularly if it is suspected that the child has progressed to brain death.

9.
(A)
The determination of brain death in children varies with the age of the child, and it is important to recognize there is no definition of brain death for a child who is younger than 7 days of age. The original Harvard description of irreversible coma required multiple examinations as well as an EEG.

10.
(B)
MRI has no role in the determination of brain death.

11.
(A)
The brain death examination consists of the following:

1. coma and apnea must coexist

2. there must be no evidence of brainstem function

• pupils are unreactive to light