MAIS CASOS PARA DIAGNÓSTICO...

Case Challenges" From Pediatric Annals
A 16-year-old Boy with Hepatosplenomegaly
Published in Pediatric Annals October 2009
A 16-year-old boy, a new immigrant from Ethiopia, was referred for investigation of hepatosplenomegaly. Past medical history was unremarkable ex... more
A 3-day-old Boy with Acute Flaccid Paralysis
Published in Pediatric Annals September 2009
A 3-day-old male newborn presented to the emergency room with poor sucking, constipation, decreased urination, weak cry, decreased activity, and labor... more
A 5-year-old Girl with Scarring
Published in Pediatric Annals July 2009
A 5-year-old black girl was brought to our pediatric dermatology clinic by her foster mother after referral from the emergency room for the evaluat... more
A 6-week-old Boy with Apnea and Abdominal Distention
Published in Pediatric Annals May 2009
A 6-week-old boy in respiratory distress presented to the Emergency Department via ambulance. Earlier that day, he woke from his nap screaming and ... more
A 14-year-old Boy with Pain in Hands and Feet
Published in Pediatric Annals April 2009
A 14-year-old boy was referred for evaluation of pain in his hands and feet. The pain was intermittent, described as an intense “burning” sensat... more
An 11-year-old Boy with Ankle Trauma
Published in Pediatric Annals March 2009
An 11-year-old boy first presented to his physician following ankle trauma. At that time, radiographs of the ankle revealed no acute osseous inj... more
A 2-month-old Girl with an Enlarging Lesion of the Nasal Root
Published in Pediatric Annals February 2009
A 2-month-old, otherwise healthy white girl presented with an enlarging lesion of the nasal root, slightly to the right of midline. The lesion was fir... more
A 10-year-old Girl with Abdominal Pain
Published in Pediatric Annals January 2009
A 10-year-old girl presented to the emergency department with a 3-day history of intermittent abdominal pain. The pain was initially described as “dul... more
An Unusual Sore Throat
Published in Pediatric Annals December 2008
A previously healthy 15-year-old Hispanic boy presented to the emergency room with a history of fever and sore throat. Both symptoms began 4 days prio... more
A 7-year-old Girl with a Pruritic Facial Eruption
Published in Pediatric Annals November 2008
Editor’s note: Each month, this department features a discussion of an unusual diagnosis in genetics, radiology, or dermatology. A description and ima... more
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QUAL O SEU DIAGNÓSTICO?

http://www.pediatricsupersite.com/section.aspx?sid=190


"Spot the Rash" From Infectious Diseases in Children
13-year-old girl with lesion on scalp
Published in Infectious Diseases in Children September 2009
A 13-year-old girl presents to your clinic stating that the mole behind her ear extending into her scalp is changing. She states the lesion has b... more
12-year-old boy admitted for febrile illness
Published in Infectious Diseases in Children August 2009
A previously healthy 12-year-old boy is admitted to the inpatient ward in mid-July for evaluation of a febrile illness. He had a rapid onset of fev... more
6-week-old girl with a facial rash
Published in Infectious Diseases in Children July 2009
A 6-week-old girl presents to your clinic with a facial rash. Her mother reports that the lesions developed about three weeks ago and appear to be ... more
A 6-year-old boy with black spots
Published in Infectious Diseases in Children June 2009
A 6-year-old boy was referred to rule out melanoma when he developed an asymptomatic “black dot” on the left tragus present for two days.... more
A 5-year-old with rash on extremities and trunk
Published in Infectious Diseases in Children April 2009
A 5-year-old boy presents to your clinic with an asymptomatic rash involving his extremities and trunk for three days (Figure 1). Further history ... more
A 4-year-old with foot laceration
Published in Infectious Diseases in Children March 2009
A previously healthy 4-year-old girl presented to our clinic to be evaluated for a possible infection after injuring herself at the beach. ... more
An 18-month-old boy with erythematous eruption
Published in Infectious Diseases in Children February 2009
An 18-month-old healthy black boy presented to your office with a three-week history of an erythematous, edematous eruption, which began around his el... more
A 2.5-year-old girl with an annular plaque
Published in Infectious Diseases in Children December 2008
A 2.5-year-old girl presented to the clinic complaining of a skin colored annular plaque on her right arm. Her mother reported it had been present f... more
A 34-week-old boy with skin lesions
Published in Infectious Diseases in Children November 2008
A boy, gestational aged 34 weeks and 4 days, was born at an outlying hospital and transferred to the neonatal intensive care unit for evaluation of ex... more
A 9-year-old boy with pruritic lesions
Published in Infectious Diseases in Children October 2008
A 9-year-old healthy boy presented to the clinic complaining of a three-day history of several moderately pruritic lesions on his lower legs. This was... more
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CME Activities
Managing Special Healthcare Needs Pediatric Annals, September 2009Screening and Testing: Genetics Pediatric Annals, August 2009Pediatric Immunization: Meeting the Challenges of the 21ST Century Infectious Diseases in Children, August 2009 Pediatric Annals, October 2008
Allergy
Pediatric Annals, September 2008
School Emergency
Pediatric Annals, August 2008
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Infectious Diseases in Children, July 2008 -->View more CME


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COVER STORY
Respiratory diagnostics tested as pandemic evolves
Rapid diagnostic testing is an evolving area of medicine that enables physicians to diagnose within hours, sometimes minutes, the condition of their patients.Full Story
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Vaccine-Preventable Diseases
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Dermatology
Emerging Diseases
Allergy, Asthma & Immunology
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Developmental and Behavioral Medicine
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Meeting Highlights
In the Journals
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Infectious Diseases in Children
Pediatric Annals
Rotavirus Resource Center
Rotavirus and Red Book 2009: An interview with Larry K. Pickering, MD, editor
Physician supports the processes of the CDC and the AAP that lead to the recommendations in the Red Book for immunization practices in general and for rotavirus in particular.Click here

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IMAGENS PARA DIAGNOSTICO...

"Spot the Rash" From Infectious Diseases in Children
13-year-old girl with lesion on scalp
Published in Infectious Diseases in Children September 2009
A 13-year-old girl presents to your clinic stating that the mole behind her ear extending into her scalp is changing. She states the lesion has b... more
12-year-old boy admitted for febrile illness
Published in Infectious Diseases in Children August 2009
A previously healthy 12-year-old boy is admitted to the inpatient ward in mid-July for evaluation of a febrile illness. He had a rapid onset of fev... more
6-week-old girl with a facial rash
Published in Infectious Diseases in Children July 2009
A 6-week-old girl presents to your clinic with a facial rash. Her mother reports that the lesions developed about three weeks ago and appear to be ... more
A 6-year-old boy with black spots
Published in Infectious Diseases in Children June 2009
A 6-year-old boy was referred to rule out melanoma when he developed an asymptomatic “black dot” on the left tragus present for two days.... more
A 5-year-old with rash on extremities and trunk
Published in Infectious Diseases in Children April 2009
A 5-year-old boy presents to your clinic with an asymptomatic rash involving his extremities and trunk for three days (Figure 1). Further history ... more
A 4-year-old with foot laceration
Published in Infectious Diseases in Children March 2009
A previously healthy 4-year-old girl presented to our clinic to be evaluated for a possible infection after injuring herself at the beach. ... more
An 18-month-old boy with erythematous eruption
Published in Infectious Diseases in Children February 2009
An 18-month-old healthy black boy presented to your office with a three-week history of an erythematous, edematous eruption, which began around his el... more
A 2.5-year-old girl with an annular plaque
Published in Infectious Diseases in Children December 2008
A 2.5-year-old girl presented to the clinic complaining of a skin colored annular plaque on her right arm. Her mother reported it had been present f... more
A 34-week-old boy with skin lesions
Published in Infectious Diseases in Children November 2008
A boy, gestational aged 34 weeks and 4 days, was born at an outlying hospital and transferred to the neonatal intensive care unit for evaluation of ex... more
A 9-year-old boy with pruritic lesions
Published in Infectious Diseases in Children October 2008
A 9-year-old healthy boy presented to the clinic complaining of a three-day history of several moderately pruritic lesions on his lower legs. This was... more
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http://http://www.pediatricsupersite.com/section.aspx?sid=190

LUPUS ERITEMATOSO NEONATAL

6-week-old girl with a facial rash
By Marissa Perman, MD
A 6-week-old girl presents to your clinic with a facial rash.
Her mother reports that the lesions developed about three weeks ago and appear to be expanding. She thought it was “ringworm” and used an antifungal cream twice a day that she had in the home. She has not seen any improvement with this therapy. This is her first child, and her pregnancy was uncomplicated. On exam, you note that the infant is well appearing and alert. Involving the forehead, temples and cheeks are a few ill-defined erythematous annular scaling patches and thin plaques. The rest of her exam is unremarkable.

The patient had a few ill-defined erythematous annular scaling patches and thin plaques on her forehead, temples and cheeks.
Photo courtesy of Anita P. Sheth

What is your diagnosis?
The diagnosis is neonatal lupus erythematosus.
Neonatal lupus erythematosus (NLE) is an uncommon condition usually associated with maternal anti-Ro (anti-SSA) autoantibodies. If the mother has no diagnosis or symptoms, her serologic autoimmunity may be indicative of systemic lupus erythematosis. Sjogren syndrome or other connective tissue disorders are often not detected until after the birth of the child. The disease is believed to be caused by maternal antibodies that pass through the placenta to the fetal circulation. In 95% of cases, the maternal antibodies are anti-Ro autoantibodies, a minority have U1-RNP autoantibodies.These antibodies gradually disappear in the child in the second half of the first year of life.

Marissa L. Perman
Cutaneous lesions typically present within the first several weeks of life but may be present at birth. They may be precipitated by exposure to small amounts of sunlight and are one of the most common manifestations of NLE. Annular erythematous, finely scaling macules, patches, papules and plaques are often found on the scalp and face. These lesions can often be confused with tinea corporis due to the scale and annular configuration. In addition, many infants may have confluent erythema in a periorbital distribution leading to an “eye mask” appearance. Other skin findings that can be seen include scaly atrophic patches, telangiectasias and discoid plaques. Sunlight is well known to exacerbate established or trigger new lesions, consistent with other types of cutaneous lupus.
The histopathology of cutaneous lesions in NLE is consistent with subacute cutaneous lupus seen in older patients and includes a lymphocytic infiltrate at the dermal-epidermal junction associated with damaged keratinocytes throughout the epidermis. There is also a mild to moderate perivascular lymphocytic infiltrate in the papillary dermis.
About one-third of children have extracutaneous manifestations of NLE. Several organ systems can be involved, although single organ involvement is the most likely finding. Cardiac involvement is the most severe and includes third-degree heart block and cardiomyopathy. Third-degree heart block usually develops during the second trimester and once established is irreversible leading to cardiomyopathy in some cases. Pacemaker placement is often required. The mortality rate of cardiac neonatal lupus is approximately 20%. This is due to anti-Ro autoantibodies binding to fetal, but not adult, cardiac myoctes and injuring the conducting system.
In addition, hepatobiliary and hematologic manifestations may be seen. Roughly 10% of children have hepatobiliary disease, along with cutaneous and cardiac manifestations. The three most common findings include liver failure consistent with neonatal hemochromatosis, cholestasis with conjugated hyperbilirubinemia and/or transient, mild to moderate transaminase elevations all typically occurring within the first several weeks after birth. Hematologic findings include most commonly thrombocytopenia followed by neutropenia, anemia or pancytopenia.
The workup in a patient with lesions suggesting NLE includes a complete physical exam, CBC with differential, liver enzymes, anti-nuclear antibody (ANA), anti-Ro (anti-SSA), anti-La (anti-SSB) and anti-U1RNP autoantibodies. If the infant has bradycardia or a murmur, an electrocardiogram and echocardiogram are indicated. The mother should also have ANA, anti-Ro, anti-La and anti-U1RNP autoantibodies evaluated. If these studies are positive, the mother should be referred for further autoimmune workup.
The course of the cutaneous lesions is usually complete spontaneous resolution by 6-12 months of age, although telangectasias may persist. The lesions may also resolve with atrophy, dyspigmentation or scarring. Sunlight exposure should be avoided, and sun protection with sun blocks and protective clothing should be used when UV exposure is unavoidable. Topical anti-inflammatory agents such as steroids have not been shown to change the course of the skin lesions of NLE.
There is some evidence that children exposed to anti-Ro autoantibodies in utero may be at risk later in childhood or adult life for developing systemic lupus, but the level of that risk is unclear. There is also a genetic risk. Asymptomatic mothers of children with NLE tend to develop signs and symptoms of autoimmunity with time. They should be counseled regarding the risk of NLE with subsequent pregnancies: The risk for future children developing NLE born to mothers with one affected child is 22%. Prevention of NLE in anti-Ro positive mothers is being studied. Treatment during pregnancy using betamethasone or dexamethasone has not been definitively shown to change outcome. IVIG therapy is now being reviewed.
Marissa L. Perman is a first-year dermatolology resident at the University of Cincinnati.
For more information:
Izmirly PM, Rivera TL, Buyon JP. Neonatal lupus syndromes. Rheum Dis Clin North Am. 2007 May;33(2):267-85, vi.
Lee LA. The clinical spectrum of neonatal lupus. Arch Dermatol Res. 2009 Jan;301(1):107-10.
Paller, Amy S, and Mancini, Anthony J. Hurwitz. Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence. Philadelphia: Elsevier, 2006; pp 581-3.
Weston WL, Morelli JG, Lee LA. The clinical spectrum of anti-Ro-positive cutaneous neonatal lupus erythematosus. J Am Acad Dermatol. 1999;40 (5 Pt 1): 675-681.

RESPOSTAS DOS TESTES DE CONHECIMENTOS...

Módulo I -1-b, 2-b, 3-d, 4-a
Módulo II- 1-c, 2-a, 3-d, 4-c
Módulo III- 1-a, 2-d, 3-a, 4-c
Módulo IV- 1-b,2-c,3-d, 4-b
Módulo V - 1-c, 2-d,3-a, 4-c
Módulo VI- 1-c, 2-a, 3-d, 4-c
Módulo VII- 1-b, 2-b, 3-d, 4-c
Módulo VIII- 1-a, 2-c, 3-b, 4-b
Módulo IX - 1-b, 2-d, 3-c, 4-e
Módulo X - 1-d, 2-a, 3-c, 4-b
Módulo XI- 1-c, 2-c, 3-d, 4-d
Módulo XII- 1-a, 2-c, 3-d, 4-b
Módulo XIII- 1-c, 2-c,3-d, 4-d
Módulo XIV- 1-d, 2-d, 3-a, 4-a
Módulo XV- 1-b, 2-e, 3-d, 4-a
Módulo XVI- 1-e, 2-?, 3-d,4-d
Módulo XVII- 1-d, 2-e, 3-a, 4-e
Módulo XVIII- 1-d, 2-c, 3-c,4-c
Módulo XIX- 1-d, 2-a, 3-a, 4-d
Módulo XX- 1-a, 2-a, 3-e,4-e
Módulo XXI- 1-a, 2-a, 3-a,4-e
Módulo XXII- 1-d, 2-c, 3-a,4-e

TESTE SEUS CONHECIMENTOS DE APLS ON LINE

CME Questions -modulo I

1: A 2-month-old presents to the ED with a temperature of 40°C. He is irritable but in no obvious distress. The triage nurse should consider this patient to be which of the following?
A: Level II triage, and place in an examination room to see the physicianB: Level II triage, and requires immediate medical attentionC: Level III triage, and place in the waiting roomD: Level IV triage, and place in the waiting room
2: Which of the following statements regarding a child-friendly examination room is correct?
A: Is generally not necessary in a busy EDB: Involves both décor and safety-proofing the roomC: Means having toys in the roomD: Requires placing children in a separate part of the ED
3: All EDs in the United States:
A: Admit children to pediatric wardsB: Have appropriate equipment and supplies for pediatricsC: Transfer all pediatric patients when necessary for higher levels of careD: None of the above
4: A 2-year-old girl has choked on a small rubber ball. When the paramedics arrive, she has no pulse and is not breathing. Hospital A has an ED and a small inpatient pediatric ward and is 2 minutes away. Hospital B has an ED, a large inpatient pediatric ward, and a neonatal ICU and is 6 minutes away. The child should be transported to:
A: A tertiary pediatric hospital by helicopterB: Hospital AC: Hospital BD: The hospital that the parents choose

CME Questions -modulo II

1: All of the following are components of the PAT except:
A: AppearanceB: Circulation to the skinC: Heart rateD: Work of breathing
2: Abnormalities in which of the following components of the PAT indicate a decompensated shock state?
A: Appearance and circulation to the skinB: Appearance and work of breathingC: Circulation to skinD: Work of breathing and circulation to skin
3: All of the following are signs to assess for shock except:
A: Effortless tachypnea, hyperpneaB: InteractivenessC: Pulse qualityD: Work of breathing
4: You are about to assess an 8-month-old boy. Based on his developmental level, which of the following techniques would be helpful?
A: Do your assessment from a standing positionB: Examine head to toeC: Offer distractionsD: Separate infant and mother

CME Questions -modulo III

1: Which newborn anatomic structure closes at birth or shortly thereafter to help with the transition from the intrauterine to the extrauterine environment?
A: Coronary sinusB: Ductus arteriosusC: Pulmonary arteryD: Ventricular septum
2: Which of the following statements regarding shock is correct?
A: Decompensated shock, by definition, exists when the blood pressure is elevatedB: First determined by the evaluation of capillary refill timeC: Fluid resuscitation is a priority in managementD: Most commonly manifests as cardiogenic–type shock in pediatric patients
3: Which of the following drugs can be a lifesaver in a newborn with congestive heart failure secondary to closure of the ductus arteriosus?
A: DigoxinB: DopamineC: FurosemideD: Prostaglandin E1
4: All of the following are reversible causes of dysrhythmia except:
A: Calcium channel blocker overdoseB: HypochloremiaC: HypovolemiaD: Hypoxemia

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© American Academy of Pediatrics, American

CME Questions -modulo IV

1: A child presents to the ED with lethargy after consuming 3 oz of his mother’s perfume. Which of the following is the most helpful bedside test for the evaluation of this patient’s altered mental status?
A: HemoglobinB: Serum electrolytesC: Serum glucoseD: Toxicology screen
2: Of the following options, which is the best method for acutely lowering increased intracranial pressure?
A: HyperoxygenationB: Intravenous steroidsC: Midline positioning of the neckD: Mild hyperventilation
3: All of the following are common complications of bacterial meningitis except:
A: Acute renal failureB: SeizuresC: SIADHD: Subdural effusion
4: All of the following are criteria of simple febrile seizures except:
A: Age 6 months to 5 yearsB: Associated with no neurologic deficitC: Fever greater than 40°CD: Last less than 15 minutes

CME Questions-modulo V

1: All of the following are associated with increased risk of cerebral edema in a child with diabetic ketoacidosis (DKA) except:
A: High BUN concentration at presentationB: High serum glucose concentration at presentationC: Low PCO2 at presentation D: Treatment with sodium bicarbonate
2: All of the following are clues to the presence of adrenal insufficiency except:
A: Acanthosis nigricansB: Ambiguous genitaliaC: HyperpigmentationD: Midline facial defects and microphallus
3: Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) should be treated with which of the following?
A: Administration of 3% saline if the sodium concentration is <130 mEq/LB: Administration of hydrocortisoneC: Administration of oral sodium and/or normal salineD: Fluid restriction unless the patient is seizing or severely lethargic/comatose 4: Which of the following statements regarding hypernatremia in patients with diabetes insipidis (DI) is correct? A: Never occurs in infants with DI because of high fluid intakeB: Occurs in all patients with DIC: Rare in older children with DI and normal thirst mechanismsD: Should be treated with 3% sodium chloride solution
CME Questions -modulo VI

1: The diagnosis of hypothermia is dependent on: A: Absence of an underlying metabolic conditionB: Core temperature less than 35°CC: Documented drop in basal metabolismD: Presence of J wave on ECG 2: Paramedics bring a 15-year-old girl to the ED. She had fallen into a frozen lake during an ice skating party and was in the water for an unknown period of time. CPR was administered on scene. On arrival to the ED, she is unresponsive. Which of the following is the best indicator that she is likely to survive? A: She has a high blood alcohol levelB: She has return of spontaneous circulation after 10 minutes of ACLS interventionsC: She is found to be mildly hypothermicD: Survival cannot be predicted 3: An 8-month-old is found abandoned in a dumpster on a cool fall evening. He is brought by police to the ED. On examination, the infant is lethargic with poor tone. The pulse is 60, the respiratory rate is 10, and the temperature is 30°C. There are no signs of trauma. Which of the following methods is the best way to rewarm this patient? A: Forced air rewarming deviceB: Warm blankets plus heat lampsC: Warm humidified O2 by ET tubeD: Warmed oxygen by ET tube plus IV fluids heated to 40°C 4: Which of the following differentiates coral snake envenomations from pit viper envenomations? A: Degree of pain and edemaB: Response to antivenin therapyC: Signs of neurologic involvementD: Small number of patients who require antivenin therapy var valid = new Validation('aspnetForm');
CME Questions-modulo VII
1: Activated charcoal will adsorb all of the following medications except: A: Ferrous sulfateB: PhenobarbitalC: SalicylatesD: TheophyllineE: Verapamil 2: A high anion gap metabolic acidosis would be anticipated in all of the following toxic ingestions except: A: Ethylene glycolB: IronC: IsopropanolD: MethanolE: Salicylates 3: A comatose adolescent patient with an acute exposure to an unknown toxin should receive all of the following therapeutic interventions except: A: DextroseB: FlumazenilC: Intravenous normal saline solutionD: NaloxoneE: Oxygen 4: A mother brings her 2-month-old daughter to the ED to be checked for carbon monoxide poisoning because their detector had sounded. The infant has normal vital signs and is sleeping. The mother complains of a headache. While waiting for the blood gas results, you place both mom and infant on 100% oxygen. Assuming the levels are slightly elevated (10), an appropriate amount of time on 100% oxygen for treatment would be: A: 15 to 30 minutesB: 60 to 90 minutesC: 180 minutesD: 240 minutes
CME Questions -modulo VIII
1: Which of the following would preclude clinical clearance of the cervical spine in a child or adolescent? A: Age of 9 yearsB: Altered level of consciousnessC: Asymptomatic and nontender abdomen with 10 RBCs/hpf on urinalysisD: Low-speed bicycle crashE: Superficial abrasions on both lower extremities 2: You are resuscitating a 3-year-old girl who was rescued from a burning house. She has singed nasal hairs and eyebrows, a history of impaired mentation when first discovered, and has had a dry cough since transport to your ED. You arrange transfer to the nearest burn center, which is 45 minutes away. The child is now awake, alert, and irritable and has an O2 saturation of 90% on a 40% FIO2 nonrebreather mask. She is hoarse, and the initial carboxyhemoglobin is 15%. You should: A: Administer 100% oxygen en routeB: Alert the transport crew to the possible need for intubation during transportC: Ask the local otolaryngologist to perform a bronchoscopy prior to transportD: Intubate the patient using RSI technique before transportE: Sedate the patient, and perform laryngoscopy to evaluate the vocal cords 3: The target PaCO2 for initial management of pediatric traumatic brain injury is: A: 15 torrB: 25 torrC: 35 torrD: 45 torrE: Does not matter 4: Surgical evaluation is necessary for which of the following trauma patients? A: Child who has evidence of visceral disruptionB: Child who is not hemodynamically stableC: Child who needs surgical managementD: Child whose injury mechanism or initial clinical findings suggest internal organ system derangementE: All of the above
CME Questions-modulo IX
1: When assessing the history of a traumatic injury, which of the following factors should raise concern about inflicted trauma? A: History is inconsistent with the development level of the childB: Injury is alleged to have been inflicted by a young siblingC: Minor mishap has resulted in a major injuryD: All of the above 2: Which of the following etiologies is the most common cause of death from inflicted trauma? A: Abusive head injuryB: BurnsC: Inflicted abdominal traumaD: Suffocation/strangulation 3: An infant with environmental failure to thrive will manifest any of the following findings except: A: Growth impairmentB: Impaired mother-infant interactionC: Skeletal dysplasiaD: Watchful, wary gaze 4: Which of the following presentations is consistent with Münchausen syndrome by proxy? A: Mother who administers Echinacea and goldenseal to her child for upper respiratory symptomsB: Mother who administers ipecac to her healthy child and complains about intractable vomitingC: Parents who refuse a blood transfusion for their hemorrhaging child because of their religious beliefsD: Parents who refuse to administer insulin to their child with diabetes because of their religious beliefs var valid = new Validation('aspnetForm'); CME Questions -módulo X
1: All of the following are classic findings and symptoms of intussusception except: A: Crampy, intermittent abdominal painB: “Currant jelly” stoolsC: HematemesisD: Vomiting 2: Pneumatosis intestinalis and portal vein gas can be viewed on all of the following imaging studies except: A: Abdominal CTB: Magnetic resonance imagingC: Nuclear medicine scanD: Plain film radiographsE: Ultrasonography 3: Which of the following complications of malrotation is the most serious? A: Bowel obstruction from compressing Ladd bandsB: Hypochloremic metabolic alkalosisC: Intermittent volvulusD: Midgut volvulusE: Sigmoid volvulus 4: All of the following are complications of Meckel diverticulum except: A: Diverticulum inflammation (diverticulitis)B: Ectopic gastritis and hemorrhageC: IntussusceptionD: Malrotation var valid = new Validation('aspnetForm');
CME Questions -modulo XI

1: Which of the following statements regarding Legg-Calvé-Perthes disease is correct?
A: Can be bilateralB: Classically presents in toddlersC: Generally seen in large, obese childrenD: Has no findings on x-ray
2: Which of the following statements regarding slipped capital femoral epiphysis (SCFE) is correct?
A: Most common in the early 20sB: Occurs when the femoral head slips anterior and superior relative to the femoral neckC: Often presents as knee painD: Treated nonsurgically
3: Which of the following statements regarding septic arthritis is correct?
A: Always yields bacterial growth from the synovial fluidB: Most common in teenagersC: Most commonly caused by N meningitidisD: Treated with joint drainage and intravenous antibiotics
4: Which of the following statements regarding children with Osgood-Schlatter disease is correct?
A: All have knee effusionsB: Have increased pain when they squat with the knee in full flexionC: Have increased pain when they squat with the knee in full flexionD: Usually play a lot of video games


CME Questions -modulo XII

1: Which of the following pathogens has been associated with aplastic crises in sickle cell disease?
A: E ColiB: KlebsiellaC: Parvovirus B19D: Salmonella typhimurium
2: Which of the following statements is correct?
A: Even when a patient has significant scrotal swelling, it is easy to differentiate between acute testicular torsion and epididymitisB: Patients with epididymitis rarely have normal urinalysis resultsC: Relief of pain with scrotal elevation is not a reliable sign in differentiating between testicular torsion and epididymitisD: Urethral discharge rarely indicates that a sexually transmitted disease is most likely responsible
3: An 8-month-old child is brought to the ED for evaluation of fever, vomiting, and listlessness. On examination, the infant is lethargic with a temperature of 103°F, a weak pulse of 160/min, a respiratory rate of 44/min, and cool, mottled extremities with a capillary refill time of 6 seconds. After evaluation of the ABCs, which of the following is the next step in management?
A: Attempt oral fluids with a rehydration solutionB: Give an intravenous normal saline bolus; if the WBC count is elevated, give parenteral antibioticsC: Obtain a blood culture, attempt a lumbar puncture, and then give parenteral antibioticsD: Obtain a blood culture, and then give an intravenous normal saline bolus and intravenous antibiotics
4: A 13-year-old girl is brought to the ED on hot summer morning after she passed out in church. According to bystanders, she was standing when she fainted. By the time the ambulance arrived, she was awake. She has no significant past medical history, and her physical exam is normal. Which of the following is the most likely etiology of her syncope?
A: Breath-holding spellB: DysrhythmiaC: SeizureD: Vasovagal



CME Questions -modulo XIII

1: A mother arrives at triage with a newly born infant that is wrapped in a blanket. He is mottled, limp, and has a heart rate of 80/min. Your first step should be:
A: Chest compressionsB: Intravenous accessC: Narcan administration IMD: Position the head and clear the airwayE: Positive pressure ventilation
2: A 15-year-old girl delivers a 34-week infant stained with meconium in the ED. The newly born infant is cyanotic with poor respiratory effort, and the pulse rate is 80/min. What is the first management priority?
A: Begin bag-mask ventilationB: Begin chest compressionsC: Insert umbilical vein catheterD: Suction the nose and mouth, and perform endotracheal suctioning
3: All of the following questions are part of the resuscitation-oriented history for a woman in labor except:
A: Do you abuse alcohol?B: Do you have twins?C: What color was the amniotic fluid?D: What is your due date?
4: A 3-day-old girl is brought to the ED by her mother with a complaint of constipation; she has not passed a stool since birth. All of the following diagnoses should be considered except:
A: Biliary atresiaB: Hirschsprung diseaseC: Hypoplastic left colonD: HypothyroidismE: Meconium plug syndrome


CME Questions-modulo XIV

1: What is the ASA classification for a 7-year-old child with occasional asthma relieved with PRN albuterol MDI puffs?
A: Class IB: Class IIC: Class IIID: Class IV
2: Which of the following agents would be a good choice for sedation of an alert and normally acting obese 9-month-old who rolled off a changing table and requires a CT scan for a possible head injury?
A: Chloral hydrate POB: Ketamine IMC: Methohexital PRD: Midazolam POE: All of the above
3: Discharge criteria following procedural sedation include:
A: 2 hours of observation after conclusion of procedureB: Return to baseline ambulation statusC: Return to baseline level of alertnessD: Return to baseline respiratory status
4: Which of the following is an advantage of the IM route of administering procedural sedation and analgesia?
A: Does not adversely affect NPO statusB: Facilitates patient-controlled analgesiaC: Facilitates titration of medicationsD: Lower probability of allergic reaction


CME Questions -modulo XV

1: All of the following definitions related to EMS are correct except:
A: Direct medical oversight—medical direction provided to paramedics by radio or telephone by a physician or nurseB: EMSC continuum of care—begins with prevention, moves through access, care, rehabilitation, and return to communityC: Indirect medical oversight—medical direction provided by written protocolD: Primary transport—transport from the scene to the EDE: Secondary transport—transport from the scene to an ICU
2: Which of the following statements regarding prehospital providers’ care of children is correct?
A: They are comfortable managing critically ill childrenB: They frequently provide assisted ventilation for childrenC: They frequently transport seriously ill or injured childrenD: They require frequent refreshing of pediatric knowledge and skills
3: All of the following treatments or services can be provided by an EMT-B except:
A: Assisted ventilationB: Cardiac compressionsC: ImmobilizationD: Manual defibrillationE: Patient transport
4: The role of the physician in EMS includes all of the following except:
A: Becoming familiar with local prehospital care providers, EDs, and transport servicesB: Emphasizing safety and injury preventionC: Maintaining office emergency preparedness and ED preparedness for childrenD: Providing funding for issues pertaining to EMSCE: Serving as a medical advisor to local EMS systems



CME Questions -modulo XVI

1: After a disaster, families should plan to be self-sufficient for:
A: 12 hoursB: 24 hoursC: 48 hoursD: 72 hours
2: Which of the following factors can precipitate problems for children with special health care needs after a disaster?
A: Inability to avoid allergensB: Lack of electricityC: Lack of refrigeration/cooling capabilitiesD: Stress and disruption in daily routinesE: All of the above
3: Which of the following statements regarding multicasualty triage is correct?
A: An objective triage system helps to optimize patient classification and resource allocationB: Children should automatically be given the highest triage prioritiesC: Responders should attempt to resuscitate all children in full cardiopulmonary arrest in a mass casualty incident settingD: Triage personnel should go to the most critical patients firstE: All of the above
4: Which of the following issues should be included in hospital disaster planning?
A: Command structure, such as Hospital Emergency Incident Command SystemB: Critical incident stress monitoring and servicesC: External disastersD: Internal disastersE: All of the above

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CME Questions -modulo XVII

1: A biological weapons attack would most likely resemble which of the following mass casualty emergencies?
A: EarthquakeB: Large bomb blastC: Release of chlorine from a train wreckD: Severe influenza epidemicE: Tornado
2: Which of the following syndromes is common to most of the high-threat biological agents?
A: Characteristic rashB: EncephalopathyC: Febrile prodromeD: PneumoniaE: Renal failure
3: Which of the following distinguishes botulism from other causes of paralysis?
A: HallucinationsB: High feverC: Intact sensationD: Normal bulbar functionE: Severe paresthesias
4: Which of the following patients poses the least potential hazard to health care providers?
A: Adolescent with untreated pneumonic plagueB: Asymptomatic adolescent with mustard agent on skinC: Child exposed to high doses of ionizing radiationD: Child with fever and extensive lesions of smallpoxE: Infant with nerve agent on clothing


CME Questions -modulo XVIII

1: What is the first step in managing a child with a tracheostomy tube and respiratory distress?
A: Assess colorB: Auscultate chestC: Remove trachesotomy tubeD: Suction tracheostomy tube
2: Which of the following can be used to clear a clogged gastrostomy tube?
A: Coca-Cola®B: Ginger aleC: Hydrogen peroxideD: PancreaseE: Pressure
3: All of the following statements regarding a central line are correct except:
A: A regular needle can be used to access an implanted portB: Commonly used tunneled central venous catheters in children include Broviac and Hickman; the distal ends rests outside the chest and can have 1 to 3 portsC: Implanted central vascular access ports have a distal end of the catheter, which consists of a reservoir covered with a self-healing rubber septumD: Tunneled central venous catheters are inserted surgically into a central vein, most commonly the subclavian, cephalic, or external jugular
4: Which of the following conditions is most likely to require a patient to have a tracheostomy?
A: BronchiolitisB: CroupC: Cystic fibrosisD: Tracheal stenosis


CME Questions-modulo XIX

1: All of the following are characteristics of an emancipated minor except:
A: College graduationB: High school graduationC: MarriedD: Military serviceE: Pregnancy
2: All of the following are valid reasons to transfer a child from Hospital A to Hospital B except:
A: Parents do not have insurance, and Hospital B is a county hospitalB: Parents request the transfer to be closer to their homeC: Parents request the transfer to obtain care from the child's pediatricianD: Required CT scan is available at Hospital B but not at Hospital AE: Required specialist is available at Hospital B but not at Hospital A
3: Which of the following statements regarding consent and confidentiality is correct?
A: Consent from a grandparent is always as legally valid as consent from a parentB: Court order is required to treat a child if a parent or guardian is not available for consentC: Filing a claim under a parent's medical insurance provides insufficient clinical detail to be considered a breach of confidentialityD: Parent or guardian consent is required before emergency care can be providedE: Under some circumstances, minors are able to consent for their own care
4: All of the following are considered to be routinely appropriate responsibilities for a physician after the death of a patient in the ED except:
A: Call in hospital social servicesB: Complete the death certificateC: Notify the medical examiner as required by lawD: Notify the organ donation service if required by lawE: Order complete postmortem imaging studies (body CT scan or skeletal survey) and additional blood tests

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CME Questions -modulo XX

1: Which of the following statements regarding a paronychia is correct?
A: Can be treated in the physician’s office or EDB: Deep space infection of the hands and feetC: Usually painlessD: Usually requires removal of the nail on the affected digit
2: Which of the following statements regarding paraphimosis is correct?
A: Associated with a phimotic ring of the foreskinB: Can be reduced electivelyC: PainlessD: Should be reduced only by a urologistE: Usually seen as part of a febrile illness
3: As a guide for estimating burn size, a child’s palm is approximately what percentage of the total body surface area?
A: 1%B: 3%C: 5%D: 7%
4: Correct application of tissue adhesive includes which of the following?
A: Complete hemostasisB: Debridement of foreign bodies or materialsC: ImmobilizationD: Thorough wound cleansing and irrigationE: All of the above



CME Questions -modulo XXI

1: All of the following statements regarding impedance pneumography are correct except:
A: Display can be affected by patient movementB: Measures chest wall movementC: Measures respiratory effortD: Measures ventilationE: Uses the ECG monitor leads
2: Which of the following statements regarding basic airway management is correct?
A: Chin-lift maneuver is acceptable for most trauma victimsB: Chin-lift maneuver is acceptable for unconscious trauma victims as long as cervical spine films are normalC: Jaw-thrust maneuver is preferred for trauma victimsD: Nasal airways can only be used in conscious patientsE: Oral airways work best in conscious patients
3: Which of the following statements regarding RSI in pediatric patients is correct?
A: Involves administration of a sedative agent and a neuromuscular blocking agentB: Preoxygenation is of little benefitC: Should almost always be conducted as quickly as possible; equipment can be gathered while the procedure is being performedD: Tachycardia is a common side effect of succinylcholine E: There is almost no indication for the use of atropine
4: Cannulation of which of the following venous sites has the highest risk of complications?
A: Brachial veinB: Distal saphenous veinC: External jugular veinD: Femoral veinE: Subclavian vein

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INVAGINAÇÃO INTESTINAL NA US

INVAGINAÇÃO INTESTINAL

Intussusception is the invagination of one segment of bowel into a distal bowel segment. The most common area of intussusception is ileocolic, but intussusception can be ileoileal, colocolic or ileoileocolic.
The peak age of intussusception is 6 to 12 months (generally 3 to 30 months but can occur at any age).
Intussusception is approximately twice as common in boys as it is in girls.
Lymphoid hyperplasia of the Peyer patches is thought to be the lead point of intussusception in most cases.
Adenovirus infection can cause lymphoid hyperplasia and predispose to intussusception.
In one third of cases of intussusception in children older than 2 years, a pathologic lead point is found. The most common pathologic lead point identified is a Meckel diverticulum. Other potential lead points include Henoch-Schönlein purpura, polyps, lymphomas, hemangiomas, intestinal duplications, and gastrojejunostomy tubes.
The classic triad of symptoms of intussusception is intermittent severe abdominal pain, vomiting, and grossly bloody or "currant jelly" stool. Unfortunately, this triad is present in only 20% of cases. Gross blood and currant jelly stool are late findings (Figure 2). Hemoccult-positive stool is common in intussusceptions, so stool should be tested for the presence of occult blood.
There are multiple cases in the literature of intussusception presenting with a chief symptom of lethargy. One proposed mechanism for the lethargy is a release of endogenous opioids in response to the pain of intussusception.
Figure 2. Photo courtesy of Michael Diament, MD.

Management – Diagnosis
A sausage-shaped mass might be palpated in the right upper quadrant.
Abdominal radiographs can suggest the diagnosis. There are two pathognomonic findings of intussusceptions: the crescent or meniscus sign, which is the rounded edge of the intussusceptum entering into the gas-filled distal bowel segment, and the target sign, which represents alternating layers of fat and mucosa (Figure 3). Other suggestive findings are absence of gas and stool in the cecum, paucity of bowel gas, a soft tissue mass, or a small bowel obstruction. A normal abdominal radiograph does not rule out intussusception.
The sensitivity of ultrasonography for the diagnosis of intussusception approaches 100%. An intussusception appears as an approximately 5-cm soft tissue mass; it can look like a target, with a hypoechoic rim surrounding an echogenic center. Other benefits of ultrasonography are lack of radiation exposure and identification of pathologic lead points.
Some centers use ultrasonography-guided air or saline enema reduction for treatment of intussusception.
Air or barium enema under fluoroscopy is diagnostic and potentially therapeutic. The success rate of nonsurgical reduction of intussusception varies with the experience of the radiologist. In experienced hands, successful reduction with fluoroscopy-guided barium enema is reported in 70% to 85% of cases. The success rate of air enema is reported to be higher than 90%. Multiple attempts at reduction might be required. The risk of perforation with barium or air enema is very low. However, a pediatric surgeon should be available in case of perforation or unsuccessful reduction.
Consider placement of a nasogastric tube if there is significant abdominal distention or bowel obstruction.
Patients must be adequately fluid resuscitated
Broad-spectrum antibiotics should be administered if there is suspicion of perforation or bowel ischemia.
Surgical reduction is indicated if there are any signs of peritonitis, or if barium or air enema does not successfully reduce the intussusception.
Intussusception will recur in up to 10% of patients.

DIAGNOSTICO DIFERENCIAL EM PACIENTE LETÁRGICO...

Differential Diagnosis
The patient who presents with lethargy poses a diagnostic challenge. The many life-threatening conditions that can cause lethargy in a child must be considered based on signs, symptoms, time course of the disease, and the patient’s age.
The mnemonic for altered level of consciousness in children is AEIOUTIPS:
Alcohol/Ammonia/Abuse
Electrolytes/Encephalopathy
Infection
Oxygen/Overdose
Uremia
Trauma/Tumor
Insulin/Intussusception/Inborn errors of metabolism
Poisoning/Psychiatric/Psychogenic
Shock/Stroke/Seizure/Shunt/Subarachnoid hemorrhage
Given the symptoms of abdominal pain, vomiting, and diarrhea, intussusception and dehydration are high on the differential.
If the cause of lethargy had been dehydration, the patient’s mental status would have improved after 40 mL/kg of normal saline. Because it did not, intussusception is more of a concern.
If the patient had had vomiting and lethargy without diarrhea, other items on the differential would be more concerning. If the patient had not had diarrhea, an intracranial mass, meningitis, encephalitis, and possibly toxic ingestion would be higher on the differential.

CELULITE OCULAR-ORBITAL E PERIORBITAL

What are the physical findings that distinguish periorbital from orbital cellulitis?
Periorbital
Orbital
Fever
Fever
Lid warmth, edema, erythema, and tenderness
Lid warmth, edema, erythema, and tenderness
Red eye
Red eye
Conjunctivitis
Conjunctivitis

Chemosis

Periocular pain

Decreased extraocular eye movement

Proptosis

Decreased vision

Papilledema
This patient does not have proptosis. She has normal vision and normal extraocular movements, so periorbital cellulitis is more likely (Figure 1). Figure 1. Marked periorbital swelling with yellow discharge.
Core Knowledge Points – Differential Diagnosis
Conjunctivitis is generally not associated with the level of lid inflammation this patient has, so a more serious diagnosis must be considered.
Periorbital cellulitis (preseptal) is an inflammation of the eyelid and surrounding skin.
Orbital cellulitis (postseptal) is an inflammation posterior to the septum of the eyelid affecting the orbit and its contents.
Next

What are the physical findings that distinguish periorbital from orbital cellulitis?
Periorbital
Orbital
Fever
Fever
Lid warmth, edema, erythema, and tenderness
Lid warmth, edema, erythema, and tenderness
Red eye
Red eye
Conjunctivitis
Conjunctivitis

Chemosis

Periocular pain

Decreased extraocular eye movement

Proptosis

Decreased vision

Papillede

Because of the history of injury to the right eye area, a CT scan of the orbit is obtained. It reveals soft tissue swelling in the periorbital region extending medially beyond the orbital septum. It also reveals a fracture of the medial wall of the orbit anteriorly on the right with associated ethmoid and maxillary sinusitis.
The diagnosis, then, is right ethmoid and maxillary sinusitis (Figures 2 and 3) and periorbital cellulitis and medial intraorbital extraconal cellulitis without periosteal abscess (Figure 3).
Figure 2. Right maxillary sinusitis. Figure 3. Fracture of medial wall of orbit; ethmoid sinusitis; orbital cellulitis.

Core Knowledge Points – Diagnosis
Organisms that cause periorbital and orbital cellulitis are similar to those that cause sinusitis and those that can enter the skin or orbits as a result of trauma:
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
Streptococcus sp.
Moraxella catarrhalis
Eikenella corrodens
Haemophilus influenzae (rare since introduction of vaccine)
Neisseria gonorrhoeae; Neisseria meningitidis; and Mycobacterium tuberculosis (unusual)
Often (35%) the cause is polymicrobial.
This patient’s history and physical findings have features common to both periorbital and orbital cellulitis. The mechanism of a fall or trauma to the skin around the eye is typical for patients with periorbital cellulitis, but it has been a reported cause of orbital cellulitis, especially with penetrating trauma to the orbit or as a result of fractures of the orbit.
In most cases, periorbital cellulitis results from trauma to the skin around the eye or from bacteremia.
Orbital cellulitis is most often caused by chronic sinusitis, with ethmoid sinusitis

Management – Diagnosis
The patient’s physical examination findings are most consistent with periorbital cellulitis: no decrease in EOM, no proptosis, no change in vision. The history of trauma, the severity of the periorbital swelling, and the elevated WBC count (14.4/mm3) and sedimentation rate (50 mm/h) are concerning enough to warrant a CT scan of the orbit. The decision to obtain diagnostic imaging is a difficult one. Some authors suggest that patients without clinical signs of orbital involvement (ophthalmoplegia, proptosis, or decreased visual acuity) can be managed initially with intravenous antibiotics. Beech and colleagues report that, of 34 patients with periorbital cellulitis, 14 had an elevated WBC count; seven of those patients ultimately required surgical intervention. None of the patients with a normal WBC count required surgery. These authors also note that patients who required surgery often had ophthalmoplegia, proptosis, or decreased visual acuity.
A CT scan of the orbits and paranasal sinuses is appropriate for patients who exhibit clinical signs of orbital cellulitis or its complications, and for those patients with periorbital cellulitis who do not respond to intravenous antibiotics or who develop complications. It is less clear whether CT imaging adds to the management of patients with elevated WBC counts and clinical evidence of periorbital cellulitis only.
The CT scan in this case reveals signs of early orbital cellulitis caused by the trauma to the orbit, which allowed for the development of sinusitis and its complications.
Case Development
The patient was treated with intravenous ceftriaxone, clindamycin, and vancomycin for 2 days, and her symptoms improved dramatically. Surgical intervention was not required.
She had no complications and was discharged with instructions to take clindamycin PO for 8 days.

ARRITMIAS CARDÍACAS-DIAGNOSTICO DIFERENCIAL

Differential Diagnosis
Sinus tachycardia: The rhythm in this case is too fast (>220 bpm) and is regular; sinus tachycardia is often slower and fluctuates with the respiratory cycle.
Multifocal atrial tachycardia (MFAT): The rhythm in this case is regular; with MFAT it is usually slightly irregular.
Atrial tachycardia
Supraventricular tachycardia (SVT)
AV nodal reentrant tachycardia (AVNRT)
SVT with bypass tract
Sinus node reentrant tachycardia
Atrial fibrillation (A-fib) with rapid ventricular response: The rhythm in this case is regular; irregular rhythms are seen with A-fib.
Atrial flutter: No flutter waves are seen in this case.
Junctional ectopic tachycardia (JET): This arrhythmia can be seen after surgery in children with congenital heart disease.


Sinus Tachycardia
Tachycardia is common in pediatric patients. It is defined by patient age (Table 1). The differential diagnosis for a narrow complex tachycardia includes sinus tachycardia, SVT, atrial flutter, A-fib, JET, and atrial tachycardia.Table 1
Age
Upper Limit for Heart Rate
0-6 months
180
6-12 months
160
1-2 years
140
2-5 years
120
5-12 years
110
Older than 12 years
100
Sinus tachycardia has its origin in the sinoatrial (SA) node and is a normal physiologic response to increased circulating catecholamines or decreased vagal tone, as might be seen in the following scenarios:
Cardiac: Physiologic response to increased cardiac output in exercise, intravascular volume depletion (dehydration, hemorrhage), anemia, CHF, ACS, tamponade, peripheral vasodilation (ie, anaphylaxis)
Pulmonary: Hypoxia, hypercarbia, asthma, tension pneumothorax, pulmonary embolus
Endocrine/metabolic: Hypoglycemia, hyperthyroidism, acidosis
Infection/fever
Psychological: Fear, pain, anxiety
Neurologic: Seizure
Medication/drug: ß-agonist (albuterol), anticholinergic (ipratropium, antihistamines), stimulants (amphetamines, cocaine, ephedrine, epinephrine, caffeine), tobacco, antidepressants, theophylline
To be certain that a tachycardia is in fact sinus in origin, there must be P waves before each QRS complex and this P wave must have a normal morphology (ie, upright in leads I, II, aVf). Given the heart rates that these children and infants can have, it can be difficult to actually discern P waves on the monitor or ECG because they are obscured by the previous T wave. Adenosine blocks conduction through the AV node and thus removes the QRS complexes for a brief period of time, at which point the underlying P waves can be examined. These P waves should have a similar rate to the rate as measured based on the QRS complexes. Clues that a tachycardia is originating in the SA node include:
The rate can vary based on stressors, activity, or respiration.
The rate can vary based on respiratory patterns, where it increases during inspiration and decreases during exhalation (this is most pronounced when the heart rate is slow and usually resolves with faster heart rates, and as such, might not be as helpful in this setting).
There can be beat-to-beat variability (SVT has constant R-R intervals) as well. The heart responds to environmental stimuli, crying, and respirations with an increase in heart rate.
The rate will likely be less than 220 bpm for infants and less than 180 bpm for children.

Management - Sinus Tachycardia
The sinus tachycardia itself should not be treated; however, an underlying physiologic derangement (as discussed earlier) should be sought and when found, treated. In most settings the sinus tachycardia will resolve with appropriate treatment of the underlying disorder.


Supraventricular Tachycardia
In pediatrics, SVT is the most common tachydysrhythmia (excludes sinus tachycardia). SVT has many different definitions; the most strict refers to any abnormal tachycardia that originates above the ventricles. According to this definition, all of the following would be classified as SVTs: atrial fibrillation, atrial flutter, atrial tachycardia, multifocal atrial tachycardia (MFAT), AV nodal reentrant tachycardia (AVNRT), sinus node reentrant tachycardia, and SVT with bypass tract. There seems to be somewhat of a consensus that this definition of SVT is too broad and should be narrowed to include narrow complex tachycardias involving a reentrant mechanism. This is the definition we shall use in this case; atrial fibrillation, atrial flutter, atrial tachycardia, and MFAT will not therefore be classified as SVTs. This leaves AVNRT, SVT with bypass tract, and sinus node reentrant tachycardias.
These three are similar in that they contain two separate conduction pathways with different speeds of conduction and different refractory periods. These two pathways become dissociated when one side of the pathway cannot conduct an arriving impulse (following a premature atrial contracture [PAC]) because it is still in its refractory period. The impulse then travels down the slow conducting pathway, which is not in its refractory period, and finally reaches the base of the other pathway (this pathway was in its refractory period before; however, it is now ready to conduct), which rapidly conducts back to the region of impulse origin. Thus begins the reentrant tachycardia. A reentrant circuit requires both antegrade and retrograde conduction. Antegrade conduction refers to normal downward conduction, usually from the atria toward the ventricles. Retrograde conduction is abnormally conducted backward or upward, usually from the ventricular to the atrial region. The SVTs are divided into categories based on where the reentrant circuits are located (SA node, AV node, bypass tract outside of the SA or AV node).
Approximately 70% of pediatric SVTs utilize a bypass tract that is located outside the AV node but between the atria and ventricle; AV reentrant tachycardia (AVRT). If this extranodal pathway can also conduct antegrade during sinus rhythm, ventricular preexcitation will occur — the classic delta wave seen in Wolfe-Parkinson-White (WPW) syndrome. If the extranodal pathway cannot conduct antegrade, and therefore is not seen on ECG, it is considered a concealed bypass tract. This SVT begins in a similar manner as AVNRT; however, there are P waves on the ECG (retrograde following the QRS complex) because it requires atrial depolarization to maintain the rhythm.
The relative frequency of AVRT and AVNRT is age dependent. In infancy, AVRT is seen almost exclusively. At approximately 2 years, the AV nodal tissue matures. As the patient ages, AVNRTs gradually begin to be seen and by adulthood account for 70% of SVTs. In childhood, 70% of SVTs are AVRTs.
20% of pediatric SVTs have the reentrant pathway within the AV node — AV node reentrant tachycardia (AVNRT). This SVT begins when a PAC occurs right after a normal sinus contracture. At this point, one half of the reentrant loop (AV node) is in its refractory period, so one half conducts down a slow pathway and then the other half conducts retrograde up the fast pathway leading back to the top and then retrograde into the atria. Given that this returning atrial impulse is arriving from an abnormal location (not from the SA node), atrial depolarization will proceed abnormally. This can be seen on the ECG by inverted P waves (the signal of atrial contracture) in leads II, III, and aVF following the QRS complex (retrograde). This pattern is seen in only 30% of patients with AVNRT. The remaining AVNRTs have the P wave buried in the QRS complex where it will not be seen.
10% of SVTs have the reentrant pathway within the SA node. These occur when there is a very early PAC that cannot be conducted through one portion of the SA node secondary to its refractory period. The PAC is conducted through the other SA tissue into the atria, depolarizes the atria, and then reenters the SA node through the portion that was refractory. This sets up the reentrant circuit in the SA node similar to the AV node in AVNRT. Since the SA node is the impulse origin, the P waves are normal in morphology and appear regularly before each QRS complex (which explains why it is often misdiagnosed as atrial tachycardia or sinus tachycardia).
After the SVT has resolved, it is crucial to obtain an ECG in sinus rhythm looking for WPW syndrome or any other underlying conduction disturbance that might have predisposed the patient to SVT. Most patients with WPW who present with tachydysrhythmias will have a narrow complex SVT. During normal sinus rhythm, these patients will have the classic delta wave with a shortened PR interval (WPW and Lown-Ganong-Levine syndrome are the only conditions that cause a shortened PR interval). The delta wave is an upsloping of the initial QRS complex. This upsloping is caused by rapid antegrade conduction from the atrium to the ventricles through the accessory pathway, thus causing ventricular preexcitation. AVNRT has an accessory pathway that is only capable of conducting retrograde and therefore does not have ventricular preexcitation and thus no delta wave.
For unclear reasons, SVT usually begins at rest but can rarely begin during exercise. No cardiac abnormalities are found in approximately half of the cases. Cardiac abnormalities associated with SVT include but are not limited to WPW (found in 10% to 20% of the cases), Ebstein anomaly, and transposition of the great vessels. Heart rates usually range from 160 to 300 bpm, with younger patients usually having a more rapid SVT rate than their older counterparts, including adults. Episodes of SVT usually end as they begin — abruptly. Lasting from minutes to days, an episode can spontaneously resolve without treatment or resolve only with intervention.
Presenting signs and symptoms depend on the age of the child. Infants might not present until their prolonged SVT has produced symptoms of congestive heart failure (tachypnea, fussiness, poor feeding, lethargy, shock, vomiting). It is rare for older children to present in heart failure because they usually complain of palpitations, rapid heart beat, shortness of breath, vague chest discomfort, presyncope, or syncope soon after the onset of the SVT and thus seek medical care.

Management – Unstable Supraventricular Tachycardia
Cardioversion: For the unstable (hypotensive/poor peripheral perfusion, altered mental status, shock) patient, synchronized cardioversion is the treatment of choice. Cardioversion is electrically resetting the cardiac conduction system. It is important to ensure that the “synchronized” option is selected on the defibrillator/cardiovertor. When this option is selected, you will see a dot or hash mark on each QRS complex. This ensures that during cardioversion the shock is not delivered on the T wave, thus preventing an R on T phenomenon and possibly resulting in ventricular fibrillation. The first attempt at cardioversion is with 0.5 J/kg and subsequent attempts with 1 J/kg. If the patient is in extremis no sedation is needed; however, if the patient is still alert, then sedation prior to cardioversion is recommended. The ideal agent for sedation would have rapid onset and offset, no hemodynamic effects, no respiratory depression, and adequate sedative effect along with some analgesic component. Unfortunately no such agent exists, and all agents have advantages and disadvantages. The clinician must select an agent based on its profile and the clinical scenario.
Etomidate (0.1-0.3 mg/kg/dose IV) is the likely agent of choice in this setting because it does not produce cardiovascular depression and only rarely causes respiratory depression. The dose can be repeated as needed for additional sedation. It is thought to produce some adrenal suppression, so it should be used with caution in those thought to be suppressed.
Benzodiazepines: The most commonly used agent is midazolam. It is given IV 0.05 to 0.2 mg/kg/dose to maximum of 2 mg/dose. The dose may be repeated every 2 to 3 minutes to a maximum of 10 mg. It has a fast onset and short duration; however, it is known to produce respiratory and cardiovascular depression.
Medications to be used with caution in this setting include:
Fentanyl (1 to 5 mcg/kg/dose IV) (max single dose 0.05 mg): Dose should be reduced in infants, typically 1 to 2 mcg/kg/dose. Caution is called for when using this agent, as fentanyl is known to produce respiratory and, to a lesser extent, cardiovascular depression.
Ketamine (1 to 2 mg/kg/dose IV) is a dissociative amnestic agent (similar to the street drug phencyclidine). It is given over 1 to 2 minutes with the ability to repeat the dose as needed. It generally causes little to no cardiovascular or respiratory depression; however, it does increase sympathetic tone (might be undesirable in this setting) and can produce emergence reactions. Although rare, it can also produce cardiovascular compromise.
Barbiturates are rarely used because they cause significant cardiovascular and respiratory depression.
Adenosine: In the unstable patient in whom vascular access is immediately available, a trial of adenosine is acceptable as long as it does not delay cardioversion. Adenosine blocks the AV node and will successfully convert greater than 90% of SVTs. It will convert SVT (or produce no change in the heart rate) in those with AVNRT and SVT with a bypass tract. Adenosine will not terminate SVTs in patients with SA node reentrant tachycardias; however, it might increase AV node blockade and thus decrease the heart rate slightly.
Adenosine dosage is 0.1 mg/kg, with a maximum first dose of 6 mg. The half-life of adenosine is approximately 10 to 20 seconds; therefore, it should be given intravascularly, as proximal as possible, and IV slam (as rapid as possible with at least 5 to 10 mL of saline flush to follow immediately either via 3-way stopcock or simultaneous needles in the same IV hub). If the first dose is ineffective, then double the dose (to a maximum of 12 mg) and administer in a similar manner. The side effects of adenosine are rare but include flushing, hypotension, bronchospasm, and asystole. Continuous ECG monitoring and external pacing equipment should be present at all times throughout administration.
Pharmacologic: Both amiodarone and procainamide may be considered in stable SVT refractory to vagal maneuvers and adenosine and in those with shock-refractory SVT.
Amiodarone (5 mg/kg IV over 20-60 minutes) is a class III antiarrhythmic because it prolongs the QT interval, but it has many other cardiac effects. It slows both the heart rate and AV nodal conduction via calcium channels and ß-blockade. It prolongs refractoriness via potassium and sodium channel blockade and slows intracardiac conduction via sodium channel blockade. Its side effects include bradycardia, hypotension (expect after administration), and polymorphic ventricular tachycardia.
Procainamide (15 mg/kg IV over 20-60 minutes) increases the effective refractory period, slows conduction, and decreases myocardial excitability of the atria, bundle of His-Purkinje system, and ventricles. It is the drug of choice in wide complex atrial fibrillation at very high ventricular response rates given the increased likelihood of WPW in this setting.
Other modes of acute treatment for unstable patients include calcium channel blockers, ß-blockers, digoxin, and transesophageal or transvenous pacing. All of these should be done only in the refractory setting and strictly under the supervision of a cardiologist.

Management – Stable Supraventricular Tachycardia
Vagal maneuvers stimulate the vagus nerve. They are nonpharmacologic interventions that increase parasympathetic tone and thus slow conduction through the AV node. This slowed conduction can just be enough to interrupt the reentrant loop and reset normal cardiac conduction. Vagal maneuvers may also assist with the identification of tachydysrhythmias. They can cause sudden termination of an AVNRT or SVT via bypass tract and gradual slowing of the rate in sinus tachycardia, atrial flutter, atrial fibrillation, and increased AV block (and thus decrease heart rate) in those with sinus node reentrant tachycardias. In the field or while establishing vascular access, vagal maneuvers are definitely worth a try, as follows:
Induce the diving reflex: Placing ice on an infant’s face or submersing a child’s face in ice water causes peripheral vasoconstriction and subsequently increased vagal tone.
Valsalva: Instruct the patient to inhale, hold his or her breath, and bear down as if to have a bowel movement and hold this position for 20 to 30 seconds. This is often slightly advanced for younger children, so an alternative is to have the child blow forcefully through a straw (or IV catheter) for as long as possible (at least 20 seconds).
Carotid sinus pressure is not generally used as a vagal maneuver for children.
Adenosine is the mainstay of treatment in the stable patient in whom vascular access is available. If after two ineffective doses of adenosine or if intravenous access is unavailable, move to synchronized cardioversion or some other pharmacotherapy.
Pharmacotherapy:
Calcium channel blockers (diltiazem 0.25 mg/kg or verapamil 0.1 mg/kg slow IV bolus) prolong the conduction time in the AV node and thus disrupt AVNRTs and SVTs with bypass tracts. Calcium channel blockers will convert 90% of SVTs to sinus rhythm and will do so within 10 minutes of administration. Do not use these medications in patients who have hypotension or known left ventricle dysfunction or who are already taking ß-blockers. Expect a transient period of hypotension after administration due to vasodilation. Use caution in infants, as verapamil has been shown to cause refractory hypotension and cardiac arrest in young children. It is not recommended in children younger than 2 years.
ß-blockers (metoprolol, esmolol, atenolol) are similar to calcium channel blockers in that they increase AV nodal conduction time. Do not use in patients with asthma or left ventricle dysfunction.
Digoxin generally should not be used in the acute setting.
Amiodarone: See the unstable management discussion.
Procainamide: See the unstable management discussion.
Cardioversion: See the discussion of cardioversion under management of unstable SVT.
Consult cardiology: Patients discharged to home should be followed by a cardiologist. Inpatient cardiology consultations should be obtained in all patients with unstable SVT or those in whom WPW is diagnosed.
Long-term management: Long-term management must always include input from a cardiologist. Most infants who present with SVT will have no recurrences after they are 1 year old and thus will require no ongoing therapy. Older children who present with SVT are more likely to have recurrences and thus require ongoing management. Long-term management depends on the severity and frequency of episodes. For those with infrequent, mild episodes that easily convert, with no ventricular preexcitation, no ongoing treatment is needed. Those with more frequent episodes, severe symptoms such as syncope, or ventricular preexcitation should probably be started on a ß-blocker, calcium channel blocker, or digoxin. Digoxin should be given only to children who do not have ventricular preexcitation. With preexcitation, digoxin can increase antegrade conduction down the accessory pathway. If these patients, who are already more prone to atrial flutter or fibrillation, develop them, there is a risk of 1:1 conduction from the atria through the accessory pathway to the ventricles. This will produce a very rapid ventricular response, possibly leading to ventricular tachycardia or fibrillation. Radiofrequency ablation is another treatment option: an interventional electrophysiologist (cardiologist) maps out the accessory conduction pathways that contribute to the SVT and then thermally ablates it with radiofrequency energy. The prognosis for patients with SVT is very good with a normal life expectancy and little to no morbidity.


Atrial Fibrillation and Atrial Flutter
Atrial flutter and fibrillation are rare in children. When present, they are usually associated with an underlying organic heart disease, postoperative cardiac surgery, or digoxin toxicity.
In atrial flutter, the atria beat at a rate greater than 240 bpm and often actually greater than 300 bpm. The ventricular rate depends on the rate of AV nodal conduction. In other words, the AV node is the gatekeeper that controls at what interval the atrial impulses will reach the ventricle — 1:1, 1:2, 1:3, or 1:4. Atrial flutter can mimic SVT, and the diagnosis is often made only when adenosine is given and the underlying P waves seen on the ECG have the classic sawtooth appearance (flutter waves).
Atrial fibrillation can be differentiated from SVT by its irregularity. This irregular rhythm is never seen in SVT.

Management – Atrial Fibrillation and Atrial Flutter
In the unstable patient with atrial fibrillation or flutter with rapid ventricular response (as for any tachydysrhythmia that is unstable), cardioversion is the treatment of choice. If this is ineffective, then overdrive pacing is usually the answer. For those with stable atrial flutter or fibrillation, medications such as ß-blockers, calcium channel blockers (avoid in infants), or digoxin are going to be the agents of choice. Before converting either of these two rhythms in the stable patient, consultation with cardiology and consideration for anticoagulation are needed.

Case Development
The child’s heart rate decreased to 90 bpm. She continued to be in no apparent distress. She was discharged home from the emergency department with cardiology follow up and had no recurrence.

SINDROME COMPARTAMENTAL

Compartment syndrome (CS) is the result of increased pressure within a closed anatomical space. Any area of the body that contains a compartment can be affected, namely the hand, forearm, upper arm, entire lower extremity, abdomen, and buttocks. As intracompartment pressures increase and exceed the perfusion pressure, tissues become ischemic and can become necrotic without timely intervention. Thus, CS is limb threatening and can be life threatening. Prognosis depends on the timeliness of diagnosis and intervention. Therefore, time is critical; 6 hours is accepted as the upper limit of tissue viability.2
Traditionally, the "6 P's" (pain, paresthesia, paresis, pallor, poikilothermia, pulselessness) were used to clinically diagnose CS; however, pulselessness and pallor are usually not present in CS.3 Additionally, poikilothermia is not a commonly used term, and it usually occurs at a point where the extremity is nonviable. Thus, only "3 P's" remain; learn them – pain, paresthesia, and paresis – and do not rely on the other three.
In the pathophysiology of CS, venous outflow resistance is increased, ultimately leading to a cessation in blood flow. CS is really a venous obstruction rather than an arterial infarction. Venous outflow is impeded when the compartment pressure exceeds about 30 mm Hg. As the compartment pressure rises, all the veins are compressed and venous outflow is blocked. Since venous outflow is blocked, perfusion of the tissues within the compartment ceases. There might still be arterial pulsation of the larger arteries within the compartment and distal to the compartment because the systolic pressure still exceeds the compartment pressure. In addition, arterial blood might continue to flow outside the compartment and/or through arteriolo-arteriolar shunts,2,4,5 thus, distal pulses might still be present. Pulsation within larger arteries, however, will not result in any capillary circulation (ie, no cellular perfusion is present) because venous outflow is blocked. Avoid this pitfall: pulselessness is not present in early cases of compartment syndrome. Do not use the presence of pulses to rule out a compartment syndrome: this will delay the diagnosis beyond the point of salvage.
Consider a more extreme example. If the two iliac arteries are ligated, there is obviously no flow through the iliac arteries. Yet, a finger placed on the iliac arteries (proximal to the ligation) would still yield pulsation. Again, the presence of pulsation does not necessarily equate to blood flow.
Similarly, pallor might not be evident in CS. The skin outside the compartment can be normally perfused since only intracompartment perfusion might be affected. Even if the venous outflow of the skin is impeded, the appearance of the skin would be that of venous congestion, not pallor.
Pain, however, is a reliable indicator of CS. Suspect CS if the patient complains of severe pain following any injury to an extremity. Often, the pain is more severe than one would expect from the injury. Severe pain after splinting or casting should raise the possibility of CS. The pain can occur at rest or with certain movements, such as passive stretching of the muscles or active flexion/extension. The pain can be described as a burning sensation, and it is not usually relieved by pain medication or splinting.
Paresthesia will ultimately develop as nerve conduction slows in hypoxic/ischemic conditions. A later finding in CS, paresis or paralysis might set in as motor neurons start to dysfunction. The extremity might also feel tense or hard.2,5
The anterior distal lower extremity is cited as the most common site of CS. The reason for this location is probably due to its high frequency of injury. The usual cause of CS is a fracture. However, the incidence of CS following a fracture is actually very small. In the setting of a fracture, CS is therefore a diagnosis of low probability but high morbidity. It is also estimated that 30% of limbs will develop CS following vascular injury.2
There are two main pathways to increasing intracompartment pressure:
Increasing the fluid content within the compartment, either by hemorrhage or from edema
Decreasing the compartment size, either by tissue constricture or by external compression2,6
Osseofascial compartments are relatively nondistensible and have a fixed volume. Thus, the introduction of fluid into or external compression of the compartment will undoubtedly raise the intracompartment pressure. There are several theories that attempt to explain the exact mechanism of the resulting decrease in tissue perfusion. One popular theory states that the increase in intracompartment pressure leads to a compression of the venous system. As the pressure in the venous system rises, the arteriovenous pressure gradient decreases. Hence, blood has a decreased tendency to flow into the capillaries. The body's compensatory mechanisms to increase perfusion pressure are eventually overwhelmed by increasing intracompartment pressures. The increased venous outflow resistance ultimately causes a retrograde blood stasis. Blood ceases to perfuse the cells, and the tissues become ischemic.4
A further complication is that hypoxic cells will release vasoactive substances such as histamine and serotonin, which serve to increase capillary permeability. As protein leaks into the interstitial space, water is pulled along with it. Thus, the intracompartment pressures continue to rise.
Prolonged ischemia (over 6 hours) will result in rhabdomyolysis and potential loss of limb. Rhabdomyolysis can lead to acute renal failure and eventual death. CPK and serum myoglobin levels might be elevated, indicating rhabdomyolysis. Dipstick urinalysis might be positive for blood but on microscopic review be negative for RBCs, indicating the presence of myoglobin in the urine.2
Radiographs of the extremity might show the presence of an underlying fracture, but the absence of a fracture does not rule out CS because there are other etiologies for CS. A CT scan might reveal areas of muscle necrosis. Obtaining a CT scan, however, should not delay treatment. Once CS is suspected, it should be acted on immediately to increase the patient's chance of recovery.
A measurement of the compartment pressure should be obtained as soon as CS is suspected. Commercial pressure measurement devices are available; there are also three generic procedures for measuring intracompartment pressure (see "Intracompartment Pressure Measurement Methods").
The level of intracompartment pressure that serves as the cutoff point for diagnosing CS is under debate. Some cite 30 mm Hg as indicative of CS, whereas others claim that 45 mm Hg is an appropriate cutoff.2
The threshold for developing CS is directly affected by the amount of blood flow to that area. As such, hypotensive patients can develop CS at lower intracompartment pressures. Thus, some advocate the use of perfusion pressure, rather than just intracompartment pressure, in determining CS. (Perfusion pressure = diastolic BP minus the intracompartment pressure.) McQueen used perfusion pressure measurements of less than 30 mm Hg as diagnostic of CS and an indication for fasciotomy.2
Intracompartment Pressure Measurement Methods
The Stryker Stic device (registered trademark, Stryker, Kalamazoo, MI) is a commercially available product made specifically for measuring intracompartment pressures. It is fast and accurate, but it is modestly expensive. Prep the skin with povidone-iodine solution. Administer local anesthesia if necessary, being careful not to inject within the compartment.
There are three generic alternatives to the Stryker Stic, two of which will probably work with equipment that is available in most hospitals.
The IV infusion pump method (probably the best alternative)
Electronic pressure transducer method
Mercury column manometer method (difficult and sometimes not reliable7).
IV Infusion Pump Method
This method is very simple, but it requires an IV infusion pump with a built-in pressure readout. Most modern IV infusion pumps have this feature, which is most commonly used to permit nurses to set limits on IV infusion pressure so that the pump will alarm if a high pressure condition is encountered, usually due to an infiltrated IV or a malpositioned IV catheter. These sophisticated pumps reduce the likelihood of an undetected infiltrated or obstructed IV catheter.
Uppal et al described the use of the IVAC infusion pump to measure the intracompartment pressure.8 The accuracy of this method has been confirmed by others7:
Prime the IV infusion pump with saline and remove all air bubbles.
Attach an 18-gauge needle to the end of the IV tubing. Infuse saline so that saline is primed through the entire needle.
Set the IV infusion pump to 25 cc/hr.
Set the pump to read pressure in mm Hg (rather than cm H2O).
Adjust the height of the IV infusion pump to be roughly level to the patient's extremity that is about to be measured.
Turn the pump on to begin infusion, then insert the 18-gauge needle with saline flowing through it at 25 cc/hr into the desired compartment.
Immediately read the infusion pressure on the pump when the needle is inserted. Some pumps have a feature to display the pressure continuously. The pressure should have gone from a value near zero to a higher value reflecting the pressure within the compartment. The pressure must be read immediately to prevent fluid from infusing into the compartment and elevating the pressure further.
Remove the needle from the compartment.
Electronic Transducer Method
Prime a standard arterial line electronic pressure transducer module with normal saline. There should be at least two IV connections. One connects to an IV pump, which should be set at a very low rate such as 10 mL/hr. The distal port should be connected to an 18-gauge needle. The pressure transducer module cable should be connected to a blood pressure module/amplifier on the patient’s monitor system.
Infuse IV fluid until the 18-gauge needle is filled with saline, then stop the IV infusion.
Place the tip of the needle at the level of the patient’s extremity to be tested, then "zero" the monitor at this level.
Insert the needle into the designated muscle compartment.
Start the IV infusion. The monitor should show the pressure rising. When it reaches a plateau, this reflects the intracompartment pressure. Stop the IV infusion.

Core Knowledge Points—Management
Since the pathophysiology of CS involves an ischemic event, it might be helpful to give the patient oxygen to increase Po2. The patient should be hydrated intravenously to prevent acute renal failure secondary to rhabdomyolysis.2,6 The involved extremity should be kept at body level so that arterial blood flow is not compromised and venous drainage is unhindered.5
The definitive therapy for CS is fasciotomy to relieve the intracompartment pressure. The emergency physician should seek immediate surgical consultation, usually with orthopedics.
Core Knowledge Points—Complications
Prognosis ultimately depends on the speed of diagnosis and treatment. However, even with timely intervention, the patient might still suffer some permanent neuromuscular dysfunction.
Volkmann ischemic contracture is the functionless, claw-hand deformity that results from untreated forearm ischemia.
Rhabdomyolysis will occur after approximately 6 hours of warm ischemia and can escalate into a bacterial gangrene infection, loss of limb, and sepsis. Acute renal failure can result from rhabdomyolysis, and if left untreated, will lead to death.9 Following a fasciotomy, there is a risk of infection. The procedure will also leave some cosmetic deformity.2
Core Knowledge Points—Clinical Pearls
CS can occur without trauma. Prolonged external compression of an extremity can occur in the setting of drug or alcohol overdose and lead to CS.
Prognosis depends on the speed of diagnosis and treatment.
Severe pain (especially with passive stretching of the muscles) and increasing neuromuscular deficits are the key clinical manifestations of CS.
The traditional sign of pulselessness is not a definitive criterion of CS. Pulses can still be palpable in CS due to arteriolo-arteriolar shunts. Do not be misled by palpable pulses.
CS is mainly a clinical diagnosis but can be confirmed by measuring intracompartment pressures.
Critically ill patients can present with a myriad of complicating factors.
Shock: Hence, a lower intracompartment pressure is needed to overcome a lower perfusion pressure. Additionally, patients who require large volume resuscitation are at risk for developing interstitial edema and subsequent CS.9
Altered mental/neurologic status: Thus, the patient might not complain of pain and/or paresthesia. Examples include patients with CNS injury or patients on narcotics.
Hypoxia and/or anemia: In which case ischemia will occur more quickly following smaller compromises in capillary perfusion pressure.
Treatment of rhabdomyolysis involves aggressive intravenous hydration to prevent acute renal failure.
Fasciotomy is the definitive treatment for CS.
Case Development
An orthopedic surgeon performed a fasciotomy of the patient’s forearm.
Large areas of muscle necrosis were noted.
He developed renal insufficiency secondary to severe rhabdomyolysis.
After multiple debridement procedures, he was able to regain some forearm, wrist, and hand function, but he suffered permanent neuromuscular deficits.
One of the patient's friends revealed that he had taken 20 or 30 shots of liquor the previous night. After he fell off the bar stool, his friends carried him into the back of a pickup truck, where he slept until he awoke the next day. His compartment syndrome was caused by his sleeping on his arm and compressing it for an extended period of time. The alcohol intoxication was significant because it blunted his body's normal protective reflexes that stimulate moving and rolling while sleeping.
The bruised lesion on his back was probably caused by pressure necrosis that resulted from something pressing on his flank while he was unconscious in the pickup truck