Document em9OVKGrXVEG0RBmqVOayGbOM

lisive cuta- rly 1968 tain and it to co e shung on of liver - treatment provement ' d that this history of ster 1938 aun et al ation with e and may infant until the lesions ltiple cutato have a The latter onths and Other usual not present he presence in the liver epatic haeroid therapy ease in liver r there was linical signs ne Hallidie- ad, Arch Arch Dis Child 1977 Se te 52 157-159 157-159 Short reports 157 Smith for performing the diagnostic radiological studies and to Dr. Pamela Davies for her help ^fin the preparation of this report The child was found choking her face covered with powder The mother cleaned the upper airways and normal breathing returned About 24 hours after the accident she developed steadily increasing References respiratory distress and was admitted to hospital Braun Physical examination 6 hours after the accident P. Ducharme J. C. and Davignon A. 1975 . showed a nourished and developed baby in _ H^'mangiomatoseh^'patiquedu nourrisson diagnostic et traitement Helvetica Paediatrica Acta 30 159 167 severe respiratory distress pulse min respira- ' deLorimier A. A. Simpson E. B. Baum R. S. and Carlsson E. 1967 Hepatic ligation for hepatic hemangiomatosis New England Journal of Medicine 277 333 337 Fost N. C. and Esterly N. B. 1968 Successful treatment of juvenile hemangiomas with prednisone Journal of Pediatrics 12 351 357 Kundstadter R. H. 1933 Hemangioendothelioma of the liver in infancy American Journal of Diseases of Children 46 803 810 Leonidas J. C. Strauss L. and Beck A. R. 1973 Vascular tumors of the liver in newborns A pediatric emergency tions min temperature 38 C The upper airways were clear Expiration was prolonged with scarce fine rhonchi over both lungs which were resonant to percussion The liver could be felt 2 cm below the costal margin TO; Laboratory results showed a capillary PCO of 42 mmHg a and leucocytosis of 15 mm 15-4 109/1 with a strong shift to the left The first ray film of the chest showed fine and diffuse alveolar American Journal of Diseases of Children 125 507 510 Lister W. A. 1938 The natural history of strawberry : naevi Lancet 1 1429 1434 McLean R. H. Moller J. H. Warwick W. J. Satran L. and Lucas R. V. 1972 Multinodular hemangiomatosis infiltrates on both sides partially confluent a barely visible interlobal fissure on the right and a small pleural effusion on the left Fig ) of the liver in infancy Pediatrics 49 563 573 Sardemann H. and Tygstrup I. 1974 Prolonged obstruc- tive jaundice and haemangiomatosis Report of 2 cases Archives of Disease in Childhood 49 665 667 Touloukian R. J. 1970 Hepatic hemangioendothelioma during infancy pathology diagnosis and treatment with prednisone Pediatrics 45 71 76 Treatment was begun with intravenous infusions ampicillin cloxacillin and prednisone During the next 3 hours respiratory distress increased the Pco rising to 58 mmHg requiring nasal intubation and controlled ventilation under neuromuscular blockade with pancuronium Loosco Baby Respira- DIANA ROBINSon and Garry Hambletont Department of Paediatrics and Neonatal Medicine Hammersmith Hospital 150 Du Cane Road London W12 OHS Correspondence to Dr. D. Robinson Present address Park Hospital Davyhulme Manchester tor IPNV with maximal inspiratory pressure Repeated vigorous bronchial washing with normal saline still showed even after many hours viscous . whitish material Besides the antibiotics and pred- nisone aminophylline orciprenaline and potassium iodide were administered However it was impos- sible to ventilate the child sufficiently because of Powder aspiration in children Report of two cases Acute aspiration of zinc or talc powder is a very dangerous condition in childhood and several fatalities have been reported Recently we saw 2 cases The first showed the classical course with delayed respiratory distress and extreme measures were needed to save the baby Using an aggressive therapeutic approach we were able to avoid acute sequelae in the second patient We report our ex- periences and give clinical recommendations Case reports Case 1. A month girl was admitted to hospital 6 hours after aspiration of Fissan Baby powder containing t^ lczinc oxide and other substances Fig 1 Case 1. Chest ray 7 hours after powder aspiration Note the alveolar infiltrates in both lungs with partial confluence and the pleural effusion on the left Protected Document to Protective order JNJ 000058436 158 Short reports tremendous airway resistance arterial blood gases 12 hours after aspiration Pao 63 mmHg with an F of 8 pH 6 Paco 99 mmHg bicarbonate 18 mEq BE 1m7Eq At this time signs of hypercapnia were most impressive with tachycardia hypertension with wide pulse pressure flushed and sweating skin and a bulging and bounding on- _ tanelle About 6 hours after starting mechanical ventilation the Paco dropped to 60-65 mmHg and the airways obstruction improved Despite hypoventilation the | day of baby was never hypoxaemic because of high F The following signs of right heart failure developed massive weight gain tachycardia hepa- tomegaly and digitalis and frusemide were given Chest ray showed early atelectasis of the| right upper lobe and bilateral basal emphysema bronchograms were seen at different levels On day 6 after the accident still with maximal respiratory pressure a sided pneumothorax developed which was treated by insertion of a chest Fig 2 Case 1. Chest ray 14 days after powder aspiration Note the confluent perihilar densities : bronchial wall thickening and atelectasis of the posterior ; . segment of the right upper lobe tube and suction 2 days later the baby again had fever and a leucocytosis with a strong shift to the wards the boy received prednisone ampicillin left the tracheal aspirate grew | Pseudomonas humidified air and acetyl cysteine by inhalation The course was uneventful and the patient recovered - aeruginosa The antibiotics were changed to gentamicin and Cephapirin On day 9 we were able to completely within 4 days change to assisted ventilation and the following day the child was extubated She remained another 10 Discussion days in hospital all treatment being gradually 7 . 7 Until now 22 cases of powder aspiration have stopped At examination before discharge she was in good general health with no neurological deficit The lungs were clear Capillary -saturation breathing room air and crying was 92 Pco 30 3m5 mHg Chest ray showed some confluent perihilar densities bronchial wall thickening and a small area of atelec- tasis in the posterior segment of the right upper . lobe Fig 2 On clinical follow after 3 months we found no symptoms and signs of respiratory tract or pulmonary disease The lungs were clear no cardiac abnormality was detected Capillary saturation was % The ray still showed some regressing right hilar densities and discrete peribronchial infiltrations An electrocardiogram was normal been reported Cless and Anger 1954 Gould and Barnardo 1972 Gouvea et al 1966 Heiman and Aschner 1922 Hughes and Kalmer 1966 Jenkins 1963 Lund and Rasmussen 1969 Molnar et al 1962 Tortorolo and Romano 1966 The patients were mainly children around 1 year of age The mortality rate was 23 Nearly always there is a characteristic silent period of several hours between the initial event and the beginning of severe respira- tory distress This asymptomatic period can lead to wrong medical decisions The respiratory distress is due mainly to bronchiolar obstruction by the aspirated powder and massive bronchitis and _ bronchiolitis with pulmonary oedema atelectasis and compensatory emphysema Our first case presented most severe lower airway Case 2. A month boy was admitted to hospital half an hour after aspiration of Merfen powder containing talc and borate of phenylmercury No signs of respiratory distress were visible but over the left lung some rhonchi were heard The initial chest ray had the same characteristics as seen in the first patient mainly alveolar infiltrates Intubation was performed under fluothane anaesthesia with intensive bronchial wash Plenty of whitish material was aspirated After- obstruction compatible with the pathoanatomical findings described in the literature Acute right heart failure pneumothorax and pseudomonas infection were secondary to the pulmonary disease or to our treatment The results obtained by Gouvea et al 1966 and those in our Case 2 justify an aggressive therapeutic approach We recommend therefore early bronchial wash or lavage in a child who has aspirated powder especially talc or zinc even if this tory d distress forced doses clinical ventilat resistan adjustn asthma F10 1 infusion especia functio ' Summ Two c mo asymp respira insuffic cal ver includ pneum recove in the media cheal opcral distre Pov obstri high r obtai wash- toms specia resist be he Refer ; Cless Asp 506 Gouk afte Chi Gouv de pet Cli Pai Heim Ste An Hugh tio 65 Protected Document to Protective order powder sities f the posterior 2 ampicillin by inhalation ient regered piration have t Gould and ; Heiman and 1966 Jenkins 1969 Molnar > 1966 The 1 year of age ways there is a ours between evere respira- id can lead to ory distressis ction bythe onchitis and a atelectasis : lower airway hoanatomical ute right heart onas infection case or to our et al 1966 gressive thera- herefore early hild whas whas r zind ven Short reports 159 " if this child presents without any sigris of respiratory distress Children already in respiratory distress should have optimal medical treatment with forced intravenous fluids corticosteroids in high Jenkins M. Q. 1963 Poisoning of the month dusting pow- of der inhalation Journal Association 59 62 the South Carolina Medical Lund J. S. and Rasmussen M. 1969 Accidental aspiration of talc Acta Paediatrica Scandinavica 58 doses and bronchodilators Depending on the clinical course and blood gas analysis mechanical ventilation may be required Very high airway 295-296 Molnar J. J. Nathenson G. and EdberSg. 1962 Fatal : powder aspiration of talcum by a child New England : Journal of Medicine 266 36 37 resistance must be overcome and respiratory adjustment should be done as in severe bronchial Tortorolo G. and Romano C. 1966 Pneumopatia acuta da inalazione di talco Minerva Nipiologica 16 15 19 asthma Hypoxaemia can be avoided by increasing Fro Respiratory acidosis may be corrected by infusion of THAM not sodium bicarbonate interferes especially when high Paco functions with vital J^ RGPFENNINGER and VINCENZO D'APUZZO _ University Children's Hospital Bern and Ospedale della Beata Vergine Mendrisio Switzerland Summary Correspondence to Dr. J. Pfenninger Intensive Care Unit University Avenue The Hospital for Sick Children 555 Toronto Ontario Canada M5G 1X8 Two cases of powder aspiration are reported A month girl showed a classical course with an asymptomatic period of 3-4 hours then severe respiratory distress developed Acute respiratory insufficiency made tracheal intubation and mechanical ventilation necessary for 10 days Complications Pyogenic meningitis in chronic gastroenteritis and marasmus included insufficient alveolar ventilation atelectasis pneumothorax and superinfection But the baby recovered with some residual radiological changes in the lungs A month boy was treated immediately after massive powder aspiration by tracheal intubation and bronchial wash The postoperative course was uneventful and no respiratory distress developed Powder aspiration leads to severe bronchiolar obstruction with a delay of several hours and has a high mortality rate The best results in treatment are obtained by immediate intubation and bronchial wash even in the absence of respiratory symp- toms Artificial ventilation may be necessary with the special problem of overcoming very high airway resistance Corticosteroids and bronchodilators may be helpful References We report a series of cases of infants presenting with a severe illness with gastroenteritic symptoms in whom the initial cerebrospinal fluid CSF was normal but pyogenic meningitis developed during the course of the illness Clinical presentation was atypical and the development of meningitis was unexpect- combination ed and unpredictable This unusual prompted this paper Case reports Case 1. A male aged 3 months was readmitted 10 days after a previous episode of chronic gastroenteritis with a history of diarrhoea for 2 days He was % dehydrated opisthotonic and after rehydration was below the 3rd centile for weight Lumbar puncture yielded sterile CSF Table Enteropathic E. coli O127 was cultured from the stool Cless, and Anger R. 1954 Erstickungstod durch Kinderpuder Aspiration von Kinder^/rztlichePraxis 22 distress 506-508 Gould S. R. and Barnardo D. E. 1972 Respiratory after talc inhalation British Journal of Diseases of the Chest 66 230 233 M. Gouvea F. P. Gonsalves P. E. Lebrun E. and Faria F. de aguda de talco e outros pos tera- 1966 Aspiracao peutica por lavagem bronquica Revista do Hospital das Clinicas de Faculdade de Medicina da Universidade de S^o Paulo 21 49 55 Heiman H. and Aschner P. W. 1922 Aspiration of stearate ofzinc in infancy clinical and experimental study American Journal of Diseases of Children 23 503 510 Hughes W. T. and Kalmer T. 1966 Massive tale aspira- tion American Journal of Diseases of Children 111 653 654 Opisthotonus persisted 2 weeks after admission the diarrhoea was severe he was pyrexial a lumbar puncture again yielded sterile CSF Table A week later the diarrhoea was stained pyrexia and opisthotonus persisted a third lumbar puncture yielded sterile CSF Table rays of chest abdomen were normal Improvement occurred until 6 weeks after admission another pyrexial episode prompted a fourth lumbar puncture which now yielded purulent CSF Table After treatment for meningitis total nerve deafness was diagnosed Case 2. A male aged 8 months was admitted with a history of diarrhoea for the previous month He was Protected Document to Protective order JNJ 000058438