MORNING REPORT JULY 23, 2012
Good Morning
Illness Script
Predisposing Conditions Age, gender, preceding events (trauma, viral
illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult What is physically happening in the body,
organisms involved, etc.Clinical Manifestations
Signs and symptoms Labs and imaging
Semantic Qualifiers
Symptoms
Acute /subacute ChronicLocalized Diffuse
Single MultipleStatic Progressive
Constant IntermittentSingle Episode Recurrent
Abrupt GradualSevere MildPainful NonpainfulBilious Nonbilious
Sharp/Stabbing Dull/Vague
Problem Characteristics
Ill-appearing/Toxic
Well-appearing/Non-toxic
Localized problem
Systemic problem
Acquired Congenital
New problem Recurrence of old problem
CXR 1:
LUL consolidation
CXR 2:
Worsening of the LUL
consolidation with
development of a small
pleural effusion
What Happens in SCD?**
Autosomal recessiveChromosome 11
Glutamine ValinePolymerization of
HgbS on de-oxygenation
Crescent shaped RBCsVascular occlusionOrgan ischemiaEnd-organ damage
Early Diagnosis**
Can be detected at birth on the NBS
Early detection = better outcome
Decreased bacteremia/sepsis (by 84%)PenVK started by 3
monthsPCV13 at 2, 4, 6moPCV23 at 2 & 5yo
ACS Predisposing Conditions
Peak age 2-4 yearsWinter monthsRecurrence higher if first episode of ACS is
before the age of 3yoOpioid usage (PO > IV) with preceding VOC
Decreased inspiratory effort Areas of atelectasis Predisposition to development of ACS
Bacteremia (in young children)Over-hydration during another illness
ACS Pathophysiology
Infectious (at least 30% associated with + sputum or BAL cultures) Strep pneumo (most common in younger children) Mycoplasma, chlamydia Staph aureus, Hib, Salmonella, Enterobacter
Fat embolus to the lungs Arises from micro-infarction to the bone marrow If large, can be life threatening
Other vascular occlusions from the sickling process
COMBINATION of ABOVE
ACS Clinical Manifestations
Fever, cough, chest pain = most commonSOB, wheeze, hemoptysis, chillsHypoxia and respiratory distressNew infiltrate on CXR
Upper lobe more common in children Can be multi-lobar Associated pleural effusion
Hgb decreased from baselineLeukocytosis+ blood cultures and/or sputum or BAL cultures
Acute Chest Syndrome
2nd leading cause of admissions after VOC**More common in children but more severe in adults
Acute Chest Syndrome
Definition The radiologic appearance of new
pulmonary infiltrate involving at least one complete lung segment plus one of the following Fever >38.5 Hypoxia Chest pain Signs of respiratory distress (tachypnea,
wheezing, cough, retractions)
Acute Chest Syndrome
Treatment Broad spectrum antibiotics
Cephalosporin (Rocephin) Macrolide (Azithromycin) +/- Vancomycin (often used here at CHNOLA)
Hydration (2/3 to 3/4 MIVF) Oxygen (goal sats >92%) Incentive spirometry and CPT Bronchodilators +/- steroids
If patient has a history of asthma Pain control
Acute Chest Syndrome
Treatment Simple transfusion
Goal Hgb close to 10g/dL EARLY!!
Exchange transfusion Progressive illness
despite treatment Significant hypoxia Multi-lobe infiltrates
Acute Chest Syndrome
Importance About 50% of SCD patients experience at
least 1 episode of ACS Significant morbiditiy and mortality Multiple ACS episodes may lead to
Chronic, restrictive pulmonary disease Pulmonary HTN
Children with recurrent episodes should be evaluated with PFTs by a pediatric pulmonologist
NOON CONFERENCE: HEME/ONC EMERGENCIES
DR. VELEZ
Thanks for your attention