Document jgnRwx3Jk35zyO9pBNbE72O75

isive cuta- rly 1968 tain and it to e shsumhum on of liver treatment provement d that this history of ster 1938 aun et al ation with e and may infant until the lesions Itiple cutato have a The latter onths and Other usual not present he presence in the liver epatic haeroid therapy case in liver r there was linical signs ne Hallidie- f coh, ff Arch Arch Dis Child Feb. , 1977 we 2 52 157-159 157-159 Short reports 157 As ; 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 P. Ducharme J. C. and Davignon A. 1975 - H^'mangiomatoseh^'patiquedu nourrisson diagnostic et traitement Helvetica Paediatrica Acta 30 159 167 Physical examination 6 hours after the accident showed a nourished and developed baby in severe respiratory distress pulse min respira- deLorimier A. A. Simpson E. B. Baum R. S. and Carlsson E. 1967 Hepatic ligation for hepatic heman- giomatosis 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 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 Tc - Pediatrics 72 351 357 2 cm below the costal margin , 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 Laboratory results showed a capillary Pco of 42 mmHg a and leucocytosis of 15 mm 15-4x 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 : nacvi 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 obstructive 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 HambleTON 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 experiences and give clinical recommendations Case reports Case 1. A month girl was admitted to hospital 6 hours after aspiration of Fissan Baby powder containing talc zinc 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 me JNJTALC000438711 158 Short reports tremendous airway resistance arterial blood gases 12 hours after aspiration Pao 63 mmHg with an F of 0.8 pH 9 Paco 99 mmHg bicarbonate 18.5 mEq BE -17-6 mEq 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 fon- . _ tanelle ; ; About 6 hours after starting mechanical ventilation the Paco dropped to 60-65 mmHg and the airways obstruction improved Despite hypoventilation the baby was never hypoxaemic because of high F10 The following day 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 tube and suction 2 days later the baby again had fever and a leucocytosis with a strong shift to the left the tracheal aspirate grew | Pseudomonas . aeruginosa The antibiotics were changed to gentamicin and Cephapirin On day 9 we were able to change to assisted ventilation and the following day the child was extubated She remained another 10 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 wards the boy received prednisone ampicillin humidified air and acetyl cysteine by inhalation The course was uneventful and the patient recovered completely within 4 days Discussion days in hospital all treatment being gradually stopped ae : 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 7 Until now 22 cases of powder aspiration have 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 % 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 under, 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 F FO O1 infusio especia functio ' Summa Two c mo asymp respira insuffic cal ver includ pneun recove in the media cheal opcra distre Pov obstr high obtain washtoms specia resist be he Rafer Cless Asp 506 Gouk afte Chi Gouv de pel Cli -,, Heim ste An Hugt tio 65 powder sities the posterior 2 ampicillin by inhalation ient regered piration have * Gould and ; Heiman and 1966 Jenkins 1969 Molnar 1966 The 1 year of age ways there is a ours between evere respira- od can lead to ory distress is ction by the onchitis and a atelectasis : lower airway thoanatomical ute right heart onas infection case or to our et al 1966 gressive thera- herefore early hild w has r zind ven Short reports 159 " if this child presents without any signs 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- der inhalation Journal of the South Carolina Medical Association 59 62 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 RomanCo. 1966 Pneumopatia acuta da inalazione di talco Minerva Nipiologica 16 15 19 asthma Hypoxaemia can be avoided by increasing Fo Respiratory acidosis may be corrected by J^ RGPFENNINGER and VINCENZO D'APUZZO . infusion of THAM especially when high functions not sodium bicarbonate Paco interferes with vital University Children's Hospital Bern and Ospedale della Beata Vergine Mendrisio Switzerland a Correspondence to Dr. J. Pfenninger Intensive Care Unit Summary 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 Pyogenic meningitis respiratory distress developed Acute respiratory insufficiency made tracheal intubation and mechanical ventilation necessary for 10 days Complications 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 tra- cheal intubation and bronchial wash The post- operative course was uneventful and no respiratory distress developed Powder aspiration leads to severe bronchiolar obstruction with a delay of several hours and has a We report a series of cases of infants presenting with a severe illness with gastroenteritic symptoms in whom the initial cerebrospinal fluid CSF was nor- mal 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 high mortality rate The best results in treatment are Case reports 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 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 Aspiration von Kinder^/rztlichePraxis 22 Kinderpuder 506-508 Respiratory Gould S. R. and Barnardo D. E. 1972 distress after talc inhalation British Journal of Diseases of the Chest 66 230 233 Gouvea F. P. Gonsalves P. E. Lebrun E. and Faria M. F. de 1966 Aspiracao aguda de talco e outros pos terapeutica por lavagem bronquica Revista do Hospital das Clinicas de Faculdade de Medicina da Universidade de S^o H. Paulo 49 55 Heiman , and Aschner P. W. 1922 Aspiration of stearate of zinc in infancy clinical and experimental study American Journal of Diseases of Children 23 503 510 Hughes W. T. and Kalmer T. 1966 Massive tale aspiration 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 JNJTALC000438713