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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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430 CASE FILES: FAMILY MEDICINE
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38.2 An 84-year-old nursing home resident underwent emergency open cholecystectomy under general anesthesia. She has advanced Parkinson disease,
hypertension, and diabetes and has been receiving nutrition via nasogastric tube (NGT) since the surgery. On the second postoperative day, she
was noted to be coughing and vomiting. Four days later, she has a temperature of 102 °F (38.8 °C), heart rate of 90 beats/min, respiratory rate of
25breaths/min, blood pressure of 120/70 mm Hg, and oxygen saturation
of 87% on room air. She has a productive cough with what the nursing
staff described as “putrid smelling and appearing sputum.” Lung auscultation shows crackles on the right, and a chest radiograph reveals a patchy
infiltrate in the right lung. Which of the following is the most appropriate
next step in management?
A. Obtain an expectorated sputum sample for culture.
B. Treat empirically with antibiotics.
C. Insert percutaneous endoscopic gastrostomy (PEG) tube for long-term
feeding.
D. Treat with a proton pump inhibitor (PPI).
38.3 A 42-year-old man underwent open reduction and internal fixation of a
comminuted fracture of the right femur, which he suffered from a motor
vehicle collision. He was recovering satisfactorily until today, the fifth postoperative day, when he complained of pleuritic chest pain. He currently has
a fever of 101 °F (38.3 °C), heart rate of 118 beats/min, respiratory rate
of 30 breaths/min, blood pressure of 130/85 mm Hg, and oxygen saturation of 85% on room air. His left ankle and calf are found to be edematous,
warm, and tender. Which of the following is the most significant risk factor
for his condition?
A. Having an intravenous line in his arm for more than 3 days
B. Failure to adequately use his incentive spirometer
C. Urinary bladder catheterization
D. Prolonged immobility
38.4 A 50-year-old woman with diabetes was recuperating from left inguinal
hernia repair. Her glycosylated hemoglobin (HbA1c) prior to surgery was
10%. During postoperative follow-up a week after surgery, the surgical site
was markedly erythematous, warm, and tender with pus. Which of the following is the next step in treatment?
A. Apply topical antibiotic to the surgical site
B. Use warm compresses alone, which will relieve the inflammation
C. Open the surgical site and drain the infected material
D. Send the patient home with prescription for oral antibiotics for 7 days
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ANSWERS
38.1 B. In the presence of severe hemodynamic changes and diffuse abdominal
tenderness, anastomosis bowel leak is the most common cause of fever in the
first 36 hours after laparotomy. The incidence varies between 5% and 19%,
and risk factors include age, male gender, poor nutrition status, left-sided surgery, and low anastomosis location. Answer A (pneumonia) would be likely
with productive cough and fever and usually occurs between 3 and 7days
after surgery. Answer C (SSI) and answer D (deep tissue abscess) would be
unlikely so soon after surgery and usually occur about 5 to 7 days after surgery; they present with a red and tender incision (SSI) or fever and localized
abdominal tenderness with deep infection.
38.2 B. This patient likely has aspiration pneumonia. She has risk factors that
include her age, functional status, recent general anesthesia, and advanced
neurologic disease. The right lower lung area is commonly affected. She
requires treatment with antibiotics that cover anaerobic bacteria. Expectorated sputum (answer A) is unreliable for anaerobic cultures because of likely
contamination by oral flora. Answer C (PEG tube placement) is not indicated
and does not have a lower risk of aspiration pneumonia than an NG tube.
Answer D (PPI) may help to prevent pneumonitis and other future problems
but would not help with the acute situation.
38.3 D. Based on the findings of a red and tender lower extremity, this patient
probably has a venous thromboembolic (VTE) disease or DVT of the left
leg, with likely embolization of the thrombus with clinical findings of PE.
The presentation of pleuritic chest pain, dyspnea, tachypnea, and low oxygen
saturation are consistent with PE. Risk factors for VTE include prolonged
immobility, vascular damage, and hypercoagulability. Answer A (intravenous
line in the arm for longer than 3 days) can lead to a superficial thrombophlebitis but not a DVT. Answer B (failure to use incentive spirometry) can lead
to atelectasis of the lung zones, but not DVT. Answer C (urinary bladder
catheterization) can predispose to UTI.
38.4 C. An incision and drainage procedure is the most important therapy for SSI.
Answer A (topical antibiotics) will not be effective in treating the patient.
Answer D (oral antibiotics alone) will not resolve the infection; use of incision and drainage is a mandatory part of the management due to the devitalized tissue and lack of blood supply to tissue in the surgical site. Answer B
(warm compresses) will be ineffective and can be used for mild pain of an
incision not related to infection.
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CLINICAL PEARLS
» Postoperative fevers in the first few days after surgery are common and
usually resolve on their own.
» A thorough risk assessment, history, and physical examination are
needed to determine if laboratory testing and antibiotics are warranted.
» The timing of the fever is useful in creating an effective differential diag-
nosis for postoperative fever.
» All unnecessary medication, catheters, lines, and tubes should be discon-
tinued in the postoperative febrile patient.
REFERENCES
Beilman G, Dunn D. Surgical infections. In: Brunicardi FC, Anderson DK, Billiar TR, eds. Schwartz’s
Principles of Surgery. 10 ed. New York, NY: McGraw Hill; 2015:135-160.
Hsu V. Prevention of health care-associated infections. Am Fam Physician. 2014;90(6):377-382.
Narayan M, Medinilla S. Fever in the post-operative patient. Emerg Med Clin North Am. 2013;
31(4):1045-1058.
CASE 39
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You are busy seeing patients in your outpatient clinic when you hear a commotion
coming from the waiting room. You go to check and find a very frantic mother
and her 2-year-old son, who is clutching his throat, coughing, drooling, and
visibly struggling to breathe. The mother endorses that just a few minutes
ago, the child was running around while eating grapes when she suddenly
heard him gagging and wheezing. Her son has an appointment for a well-child
examination, and he has apparently been doing well, with no significant history
of respiratory illness. The toddler is still conscious but unable to talk, and his
cough is becoming weaker. Breath sounds are decreased bilaterally. There are
audible wheezing and stridor. You try to ventilate the patient with the chin-lift
maneuver, but the chest fails to rise. You open the mouth but are unable to see
any foreign object.
▶ What is the most likely diagnosis?
▶ What is the next step in the management of this patient?
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ANSWERS TO CASE 39:
Acute Causes of Wheezing and Stridor in Children
Summary: A 2-year-old boy presents with
Acute onset of coughing, choking, drooling, and wheezing while eating grapes
Inability to speak and a cough that is weak
A good state of health prior to the incident and no history of respiratory illness
Decreased breath sounds, wheezing, and stridor
No chest rise on ventilation attempt
No foreign object seen in his mouth
Most likely diagnosis: Foreign body airway obstruction (FBAO).
Next step in management: Heimlich maneuver (subdiaphragmatic abdominal thrusts).
ANALYSIS
Objectives
1. Identify the illnesses, other than asthma, that cause acute wheezing in
children. (EPA 1, 2)
2. Understand the steps in the diagnosis and management of a wheezing child.
(EPA 3, 4)
Considerations
Acute onset of wheezing in an otherwise healthy child similar to the above case
should raise the suspicion for foreign body airway obstruction. Witnessed swallow-
ing followed by choking is not necessary for diagnosis, but as much information as
possible should be gathered surrounding the onset of symptoms. FBAO is common
among children aged 6 months to 3 years old, accounting for approximately 70% of
cases. Small toys and objects, balloons, and food (eg, nuts, grapes, and candies) are
high-risk objects for aspiration. Older children may be able to identify the object
they swallowed and assume the posture of clutching their neck with their hand,
which is the universal choking sign. One should not attempt to remove the foreign
object from a child who is actively coughing and able to vocalize. Blind finger sweep
is not recommended because of the danger of further obstruction or injury.
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APPROACH TO:
Wheezing and Stridor
DEFINITIONS
HEIMLICH MANEUVER: Performed in children greater than 1 year of age and
in adults by standing or sitting behind the person who is choking and placing the
thumb side of one fist between the navel and the xiphoid process. The other hand
grasps the fisted hand and a series of upward abdominal thrusts are delivered to
create an “artificial cough” in a choking victim in an effort to dislodge the object
blocking the airway.
STRIDOR: Wheezing coming from obstruction of the large airway that has a
constant pitch and intensity throughout the entire inspiratory effort.
WHEEZING: A musical sound heard on pulmonary auscultation produced by the
oscillating walls of airways narrowed by mucus, inflammation, and so on.
CLINICAL APPROACH
Among the many causes of wheezing in children, asthma and viral infections are
most common. Worldwide studies showed that approximately 10% to 15% of
infants wheeze in the first 12 months of life. The diagnosis of wheezing hinges
on accurate history, physical examination, laboratory tests, and even response
to treatments. It is also important to gather information regarding the age of
onset, exposure to cigarette smoke, presence of allergic signs and symptoms, frequency of wheezing, association with vomiting or feeding, and other accompanying symptoms.
The etiology of acute wheezing in children could be infectious (eg, bronchiolitis) or mechanical obstruction (eg, FBAO). Recurrent wheezing, on the other
hand, encompasses anomalies of the tracheobronchial tree (eg, bronchomalacia),
cardiovascular disease (eg, vascular rings and slings), gastroesophageal reflux, and
immunologic disorders (eg, bronchopulmonary dysplasia, cystic fibrosis). This case
concentrates on acute onset of wheezing other than asthma in children (Case 56
provides a more detailed discussion of asthma).
Foreign Body Airway Obstruction
As in the case presented above, symptoms of FBAO include weak cough, inability
to speak or cry, high-pitched sounds or no sounds during inhalation, cyanosis,
choking, vomiting, drooling, wheezing, blood-streaked saliva, and respiratory
distress. Suspected FBAO requires emergent intervention. Physical findings of
unilateral wheezing, unequal or decreased breath sounds, and stridor are common.
In children, the foreign body could lodge on either side of the airway. Eight out of
ten times, the foreign body lodges in one the bronchi. If the foreign body lodges in
the esophagus, acute wheezing is still possible when the obstruction compresses
on the airways.
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If a child older than 1 year is no longer able to cough, vocalize, or breathe, a
series of abdominal thrusts (Heimlich maneuver) should be the next step to try to
expel the foreign body. In children younger than 1 year of age, instead of abdominal
thrust, a series of five back blows alternating with chest thrusts is performed. If the
child continues to deteriorate even after 1 minute of resuscitative efforts and these
maneuvers fail to expel the foreign object, the emergency medical services system
should be activated while continuing cardiopulmonary resuscitation.
In the hospital setting, a bronchoscopic procedure is the treatment of choice.
Chest x-ray is often normal, but in some cases it shows a radiopaque foreign object
or identifies localized hyperinflation and/or atelectasis. Most deaths from FBAO
occur in children younger than 5 years of age; 65% of the children are infants.
Bronchiolitis
Pathophysiology. Bronchiolitis affects more than one-third of children under 2 years
of age and is the most common acute cause of wheezing, especially in infants who
are 1 to 3 months old. Infants younger than 6 months, premature infants, and
infants with preexisting cardiopulmonary conditions are most severely affected,
owing to smaller, more easily obstructed airways and a decreased ability to clear
secretions. Bronchiolitis is a viral infection causing nonspecific inflammation of the
small airways and usually occurs during the winter months. Respiratory syncytial
virus (RSV) accounts for 50% to 80% of cases; the rest are caused by parainfluenza, adenovirus, influenza, Mycoplasma pneumoniae, Chlamydia pneumoniae, and
human metapneumovirus. These viruses and atypical bacteria elicit inflammatory
and immune responses that produce mucus, edema, and cellular debris that block
the small airways. Influenza vaccinations in infants and toddlers have reduced the
incidence of bronchiolitis caused by the flu virus.
Clinical Presentation. Initially, the child develops nasal congestion and rhinorrhea for 1 to 2 days, followed by low-grade fever, wheezing, cough, irritability, and
varying degrees of dyspnea. Affected children may have poor oral intake and possibly dehydration. Symptoms reach a peak in 2 to 5 days and gradually resolve in 1 to
2 weeks. Physical examination may reveal wheezing, fine crackles, prolonged expiratory phase, tachypnea, and increased work of breathing, as evidenced by nasal
flaring, intercostal retraction, and even apnea. Other physical findings may include
otitis media, irritability, and hypothermia or hyperthermia.
Diagnosis. The diagnosis of bronchiolitis is based on clinical presentation, the
patient’s age, seasonal occurrence, and findings from the physical examination.
Tests are typically used to exclude other diagnoses, such as bacterial pneumonia, sepsis, or heart failure, or to confirm a viral etiology and determine required
infection control for patients admitted to the hospital. Current literature does not
support the routine use of laboratory tests, as they do not alter clinical outcomes
unless the child is less than 3 months (90 days) of age with the need to rule out
secondary bacterial infection. If the diagnosis is doubtful or the clinical presentation is concerning for other diagnoses, one may request a chest x-ray. Radiologic
findings in individuals with bronchiolitis are variable and may include bronchial
wall thickening, tiny nodules, linear opacities, and patchy atelectasis. Infiltrates and
lobar consolidation are more consistent with pneumonia.
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Management. RSV bronchiolitis is a self-limited disease and can be safely
managed in an outpatient setting. However, disease manifestation can be variable, and risk factors for severe disease include preexisting cardiac or pulmonary
disease, premature birth, very young age (< 2-3 months), nosocomial RSV infection, and, in some studies, low socioeconomic status. Patients who are in severe
respiratory distress; those younger than 3 months old or premature; those with
comorbid conditions, lethargy, hypoxemia, or hypercarbia; and those with atelectasis or consolidation in chest radiograph need to be hospitalized. The single
best indicator of severity is low pulse oximetry. Indicators of mild disease include
good oral intake, age greater than 2 months, oxygen saturation greater than or
equal to 94%, and normal age-based respiratory rate (<45 breaths/min for
0-2months old, <43breaths/min for 2-6 months old, and <40 breaths/min
for 6-24months old).
Supportive Care. The Agency for Healthcare Research and Quality, in collaboration with the American Academy of Family Physicians and the American Academy
of Pediatrics, recommends supplemental oxygen if SpO2 (oxygen saturation mea-
sured by pulse oximetry) is < 90% and supportive care as the modes of treatment with
clear evidence of effectiveness in RSV bronchiolitis. Supportive care should consist
of supplemental humidified oxygen, fluids, and the suctioning of nasal and pharyngeal secretions; the most important therapy is humidified oxygen. Medications
have a limited role in the management of bronchiolitis.
Pharmacological Interventions. Several drugs are commonly used, but little or
inconclusive evidence supports the routine use of any drug in the management of
bronchiolitis. Nebulized bronchodilators, cool mist, steroids, antibiotics, and ribavirin have insufficient evidence or have not been shown to help in previously healthy
children. Passive immunoprophylaxis (RSV immunoglobulin or palivizumab) just
before the beginning of RSV season has been proven to be an effective preventive therapy for children younger than 2 years with increased risks from chronic
lung disease or history of prematurity (less than 35-week gestation), or for children
younger than 4 years with acyanotic congenital heart disease.
Croup
Pathophysiology. Croup is a very common cause of airway obstruction in children
aged 6 months to 6 years, and it is a leading cause of hospitalization for children
younger than 4 years. It is a viral infection that causes inflammation of the subglot-
tic region of the larynx that produces the characteristic barking cough, hoarseness,
stridor, and different degrees of respiratory distress that are more severe at night.
The croup syndrome encompasses laryngotracheitis, laryngotracheobronchitis,
laryngotracheobronchopneumonitis, and spasmodic croup.
Croup usually occurs during fall and winter. The parainfluenza viruses (I, II, III)
are responsible for up to 80% of croup cases, with parainfluenza I accounting for
most episodes and hospitalizations. Other pathogens include enterovirus, human
bocavirus, influenza virus A and B, RSV, rhinovirus, and adenovirus in approximate order of frequency. In communities with low measles immunization rates,
measles should be listed as a rare but possible cause. Influenza A has been implicated in children with severe respiratory compromise.
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Clinical Presentation. The prodrome is characterized by 12 to 72 hours of runny
nose and low-grade fever, followed by a barking cough and variable levels of respi-
ratory distress, usually at night. Hypoxia only occurs in severe cases. These symptoms peak from 1 to 2 days and, in most cases, resolve in 1 week.
Evaluation. Diagnosis is made through clinical presentation. However, imaging studies may confirm the diagnoses. Frontal neck x-rays show the “steeple sign,”
which is indicative of subglottic narrowing of the tracheal lumen. When the diagno-
sis is uncertain, computed tomography (CT) scan of the neck offers a more sensitive evaluation, but it is rarely indicated. Treatment is geared toward the severity
of the croup (the level of respiratory distress). The most reliable clinical features
to test severity are resting stridor and chest wall retractions. Use of pulse oximetry
can also help assess severity.
Emergency Treatment. Emergency management of croup should begin with
assessment of airway obstruction; oxygen should be used liberally. Chest radiographs rarely are of use but can be an option if other pulmonary conditions are
strongly considered. Lateral neck films can be considered if there is concern for
epiglottitis or bacterial tracheitis. There is no proof that humidified air is of value,
and mist tents should be avoided. Hospitalization is appropriate if severe croup
is clinically apparent. Severe croup is exemplified by cyanosis, decreased level of
consciousness, progressive stridor, severe stridor, severe retractions, markedly
decreased air movement, toxic appearance, severe dehydration, and social factors
limiting adequacy of outpatient monitoring. Children who are hospitalized with
croup should be monitored closely, and frequent physical examinations need to be
performed.
Pharmacological Management. The current cornerstones of treatment are glu-
cocorticoids and nebulized epinephrine. Steroids have proven beneficial in severe,
moderate, and even mild croup. Dexamethasone 0.6 mg/kg by mouth or parenterally as a single dose is beneficial because of its long half-life and anti-inflammatory
action, which decreases laryngeal mucosal edema. It also decreases the need for
salvage nebulized epinephrine. Nebulized racemic (mixture of d-isomers and
l-isomers) or L-epinephrine is typically reserved for patients in moderate-tosevere distress. It works by adrenergic stimulation, which causes constriction
of the precapillary arterioles, thereby leading to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its beta-2-adrenergic
activity leads to bronchial smooth muscle relaxation and bronchodilation. The
following medications should be avoided: sedatives, opiates, expectorants, and
antihistamines.
Epiglottitis
Pathophysiology. Epiglottitis is a bacterial infection of the supraglottic tissue and sur-
rounding areas that causes rapidly progressive airway obstruction. It usually affects
children younger than 5 years old and is most commonly caused by bacteria such
as Streptococcus pyogenes (group A beta-hemolytic Streptococcus) and Haemophilus
influenzae. With the introduction of the H. influenzae type b (Hib) vaccine, there
has been a 10-fold decrease in cases of childhood epiglottitis, with group A strep
now the leading infectious etiology.
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Clinical Presentation. Within 24 hours, the patient with epiglottitis will
appear “toxic” and develop fever, severe sore throat, muffled speech (“hot potato
voice”), drooling, and dysphagia. The child usually is noticeably anxious and
assumes the sitting position, leaning forward on outstretched arms with chin
thrust forward and neck hyperextended (tripod position) to increase the airway
diameter.
With progression of airway obstruction, the patient may begin to have wheezing and stridor. Epiglottitis is a medical emergency, and visualization to confirm the
presence of severely erythematous epiglottis is preferably done in the operating room
with an experienced surgeon or anesthesiologist. Mortality rates as high as 10% can
occur in children whose airways are not protected by endotracheal intubation.
With endotracheal intubation, mortality is less than 1%.
The radiographic finding that is characteristic of epiglottitis is the “thumb
sign” or protrusion of the enlarged epiglottis from the anterior wall of the hypopharynx; it is seen on lateral neck x-ray. Blood tests should be avoided unless
there is the ability to immediately intubate, since the blood draw can provoke
anxiety and worsen the respiratory status.
A complete blood count usually shows leukocytosis, neutrophilia, and
bandemia.
Treatment. Medical treatment begins by evaluating airway, breathing, and circulation. The patient should be kept in a calm environment to prevent sudden airway
obstruction due to patient distress. Supplemental oxygen administration, a nonthreatening initial step, is easily accomplished with blow-by oxygen administered
by a parent. Equipment needed for emergent airway management should be placed
at the bedside, and the patient should be kept in view at all times. The clinician
should avoid oral and throat examinations, which can provoke anxiety and acute
obstruction.
If acute respiratory arrest occurs, ventilate the child with 100% supplemental
oxygen, using a bag-valve-mask device, and arrange for intubation. When a child
has a respiratory arrest and appropriate surgical personnel are unavailable, the
attending physician may attempt intubation. Alternative methods to gain immediate control of the airway, such as needle cricothyrotomy, are considered temporary
until a more permanent procedure (eg, tracheostomy) can be performed. The best
setting for an endotracheal intubation is in an operating room with the patient
under general anesthesia.
Treatment consists of appropriate antibiotics (second- or third-generation cephalosporins or ampicillin/sulbactam) and airway management, usually in an intensive care unit setting with a team ready to respond for intubation or tracheostomy.
Bacterial Tracheitis
Bacterial tracheitis is an uncommon life-threatening infection most often seen
in 5- to 8-year olds. It often follows an upper respiratory infection that suddenly
worsens with high fever, stridor, and cough. Patients appear toxic. Secretions are
so thick that they threaten to obstruct the upper airway. Patients should be treated
similarly to those with epiglottitis, with the patient ideally going to the operating
room for sedation, intubation, and bronchoscopy for cultures and suctioning
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