Treatment of hydrocarbon pneumonitis. High frequency jet ventilation as an alternative to extracorporeal membrane oxygenation.

A child presented with hydrocarbon ingestion leading to pneumonitis and adult respiratory distress syndrome (ARDS). Treatment with conventional ventilation in this child led to very high pressures and pulmonary air leaks. Treatment with high frequency jet ventilation (HFJV) resulted in less barotrauma, resolution of air leak, and clinical improvement. Thus, HFJV is an acceptable alternative to both conventional ventilation and extracorporeal membrane oxygenation in the treatment of hydrocarbon pneumonitis leading to ARDS.

Acute myocarditis associated with Shigella sonnei gastroenteritis.

We describe two patients with acute myocarditis temporally associated with an acute Shigella sonnei gastroenteritis. This association has not been described in children and should be considered in children with shigellosis who do not respond to rehydration therapies.

Can the need for a physician as part of the pediatric transport team be predicted? A prospective study.

OBJECTIVES: To evaluate the quality of objective information obtained during telephone requests for the transport of pediatric patients. To evaluate the ability of subjective judgment, the Pediatric Risk of Mortality (PRISM) score, and the presence of tachycardia for age to predict the need for a physician on as a member of the pediatric transport team. DESIGN: Prospective data collection. SETTING: The pediatric transport program of a children's hospital. PATIENTS: All 129 infants and children transported over a 4-month period. MEASUREMENTS AND MAIN RESULTS: We defined an objective measure of the need for a physician's presence during the transport of a pediatric patient, based on either the necessity for procedural or medical interventions during the time of transport or on direct admission to the pediatric ICU after transport. At the time of initial telephone contact, a physician's subjective opinion of the need for physician presence was recorded, a PRISM score was derived, and the presence of tachycardia (adjusted for age) was determined. Subsequently, the vital signs recorded on the record of this request were compared with those vital signs charted at the referring hospital at the time of the initial telephone request. A total of 96% of vital signs obtained during the initial telephone contact were consistent with those percentages in the referring hospital medical records. Fifty (39%) of 129 transported patients required procedural or medical interventions or pediatric ICU admission. Subjective judgments predicted physician need with a high sensitivity (0.98), but with a low specificity (0.18). PRISM score predicted 62 (48%) of 129 transports to be "physician-required" (sensitivity = 0.72; specificity = 0.67). There was no statistical association between tachycardia for age and the objective need for a physician's presence. CONCLUSIONS: Objective information obtained during request for transfer was reliable. At the time of request for transfer, subjective judgment, PRISM score, and the presence of tachycardia did not predict the need for a physician presence during transport.

Management of the child with severe brain injury.

The pathophysiology and clinical management of acute brain injury in infancy and childhood are presented using acute traumatic brain injury as a model. The principles of stabilization, transport, and intensive care management are critically reviewed.

Successful reinnervation of the diaphragm after phrenic nerve transection.

A 16-month-old infant presented with bilateral diaphragmatic paralysis and respiratory failure after removal of a thoracic teratoma. Right diaphragmatic function recovered after end-to-end anastomosis of a transected phrenic nerve. We conclude that phrenic nerve repair can restore diaphragmatic function and should be attempted in selected cases of diaphragmatic paralysis due to phrenic nerve injury.

Use of intravenous isoproterenol for status asthmaticus in children.

The use of continuous drip iv isoproterenol was studied to determine its efficacy and indications in lower doses in severe asthma. Thirty-seven patients (6 months to 16 yr) received iv isoproterenol with asthma score of 6 (mean 6.8) or greater indicating PCO2 of 60 torr or higher or a PCO2 of 55 (mean 58.4) torr or greater without response to therapeutic levels of aminophylline, corticosteroids, and aerosolized isoetharine as well as appropriate oxygen. The initial dose of isoproterenol was 0.05 microgram/kg X min; if there was no response in PCO2, the continuous drip was increased by increments of not more than 0.05 microgram/kg X min every 15-20 min; iv aminophylline was continued by continuous infusion at therapeutic levels. The isoproterenol was infused until the PCO2 less than or equal to 40 torr and maintained at that dose for an equal time, then decreased over an interval equal to the response and maintenance time. There was complete response in 34 patients (mean dose 0.2 microgram/kg X min; mean response time 1.3 h, range 0.2-3.2 h). One patient had a partial response but the isoproterenol was discontinued with reversal of an arrhythmia; a 2nd patient had initial resolution but had rebound bronchospasm when the isoproterenol was abruptly discontinued. Thus, iv isoproterenol at lower initial and responding dose is effective for reversing increased PCO2 and impending respiratory failure in status asthmaticus in children, but the limitations and complications must be closely monitored.