Moderator EMEDPA Posted March 28, 2023 Moderator Share Posted March 28, 2023 Thoughts? Intervention? 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 28, 2023 Author Moderator Share Posted March 28, 2023 7 yr old male with 1 week of progressive sob, abd pain, fever, weakness, and cough. 88% on RA. Tachy to 170. Lactic acid 3.5. Quote Link to comment Share on other sites More sharing options...
polarbebe Posted March 28, 2023 Share Posted March 28, 2023 (edited) I don’t work in the ER (anymore)… Patient is barely compensating from obstructive shock. Increased intrathoracic pressure, compressed left lung pulmonary vessels increases RV afterload, patient likely hypovolemic due to infection with poor PO intake and insensible losses, heart shifted to right of chest decreases compliance of heart (due to external compression) which decreases the preload of the heart and therefore stroke volume and cardiac output, also pressurized thoracic cavity decreases IVC return… Patient has a lactate. Shift of the mediastinal structures to the contralateral side (heart and trachea deviated to right) indicates a space occupying lesion/volume likely a fluid. Needs broad work up but based on hx most likely infectious etiology… broad spectrum abx, CT and probably a thoracentesis (mindful of re-expansion pulmonary edema). Edited March 28, 2023 by polarbebe 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 28, 2023 Author Moderator Share Posted March 28, 2023 bingo. All of the above. Emergent thora done with 1200 cc of pus drained from L chest after CT chest/abd/pelvis did not demonstrate a malignancy or solid lesion. triple abx with rocephin/vanco/zithromax, aggressive fluid resuscitation, lifeflight to peds tertiary care ctr for peds icu admit. 2 Quote Link to comment Share on other sites More sharing options...
Mayamom Posted March 29, 2023 Share Posted March 29, 2023 How long was the child sick for??? Although I do know they condition can change quickly. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 29, 2023 Author Moderator Share Posted March 29, 2023 1 hour ago, Mayamom said: How long was the child sick for??? Although I do know they condition can change quickly. 8 days. The cxr after the thoracentesis and chest tube looks basically normal. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 29, 2023 Author Moderator Share Posted March 29, 2023 1 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted April 7, 2023 Share Posted April 7, 2023 Uggh I am so late to this one. Between getting more experience in CCM and trying to also keep up with EM I haven't been on here probably going to post a update with a cool case story in a bit. This has been already addressed well but I do have a few questions about the case. What was the WBC count? Elevated CRP? Was a troponin done to just be sure no cardiac damage occured from over a week of tachycardia in the 170s? If so what was it? Also any updates if the child made a full recovery? (As a PA in EM I understand the difficulty in getting a update so if they isn't one that's completely fine) Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 7, 2023 Author Moderator Share Posted April 7, 2023 CRP and wbc both very high. don't remember #s. Trop not done. Child made a full and uneventful recovery. No one ever figured out why the kid developed an empyema out of the blue. 1 Quote Link to comment Share on other sites More sharing options...
ChrisPAinED Posted April 7, 2023 Share Posted April 7, 2023 8 hours ago, EMEDPA said: CRP and wbc both very high. don't remember #s. Trop not done. Child made a full and uneventful recovery. No one ever figured out why the kid developed an empyema out of the blue. Glad the little guy made a recovery Quote Link to comment Share on other sites More sharing options...
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