Adolescent Seizure in the Emergency Department Due to Concomitant Brugada Syndrome.

Brugada syndrome is an increasingly discussed entity in the emergency medicine and cardiology literature. However, there are few cases reported in the pediatric population. Seizure is a presentation common to pediatric emergency departments. This case report describes the clinical course, workup, and differential diagnosis of a 15-year-old male adolescent with first-time seizure and Brugada pattern on electrocardiogram. A brief review of the literature follows the case presentation.

Impact of positive end-expiratory pressure on cardiac index measured by ultrasound cardiac output monitor*.

OBJECTIVES: To evaluate the impact of different levels of positive end-expiratory pressure on cardiac index in children receiving mechanical ventilation. To explore the effect of lung recruitment on the relationship between positive end-expiratory pressure and cardiac output. DESIGN: Prospective, single center, and interventional. SETTING: PICU in a tertiary care children's hospital. PATIENTS: Fifty mechanically ventilated, hemodynamically stable children between 1 month and 20 years old. INTERVENTIONS: Positive end-expiratory pressure was altered to levels of 0, 4, 8, and 12 cm H2O in random order. Cardiac output was measured at different levels of positive end-expiratory pressure by continuous wave Doppler ultrasound (ultrasound cardiac output monitor). Baseline vital signs were recorded, as well as cardiac index and dynamic compliance of the respiratory system at each positive end-expiratory pressure level. MEASUREMENTS AND MAIN RESULTS: Median cardiac index decreased marginally as positive end-expiratory pressure increased, with a median change in cardiac index of 0.4 (< 10%) between positive end-expiratory pressure of 0 and 12 cm H2O (p < 0.001). There was no difference in heart rate or blood pressure as positive end-expiratory pressure increased (p > 0.5). For a subset of 29 patients (58%) in whom the highest dynamic compliance was at a positive end-expiratory pressure of 4 or 8 cm H2O, there was no difference in cardiac index between positive end-expiratory pressure 4 below versus positive end-expiratory pressure at highest dynamic compliance, or cardiac index between positive end-expiratory pressure 4 above versus positive end-expiratory pressure at highest dynamic compliance (p > 0.2). Regardless of optimal dynamic compliance, cardiac index decreased as positive end-expiratory pressure increased (p = 0.02). CONCLUSIONS: In hemodynamically stable mechanically ventilated children, although there is a statistically significant decrease in cardiac output as positive end-expiratory pressure is increased between 0 and 12 cm H2O, the mean change is less than 10%, and this is likely not clinically significant. In the presence of lung disease, intensive care physicians should feel less reluctant in their use of positive end-expiratory pressure for hemodynamically stable patients.

Spontaneous tracheal rupture: a case report.

BACKGROUND: Upper-airway disruption is a rare but potentially life-threatening phenomenon. It can occur spontaneously, be due to trauma, or be iatrogenically induced. Even more rare are such events reported in the pediatric population. OBJECTIVE: This article discusses the presentation, diagnostic difficulties, and management of spontaneous tracheal rupture in a child. CASE REPORT: A 3-year-old boy was brought by emergency medical services to our emergency department with a presumptive diagnosis of anaphylaxis. With progressive swelling and respiratory distress, the patient quickly deteriorated. He received i.v. epinephrine, chest compressions, and bag-valve mask ventilation. He was intubated without difficulty and with no noted airway edema. Concomitant bilateral needle thoracostomies were performed and subsequent bilateral tube thoracostomies were placed. Immediately after intubation and chest tube placements, the patient's oxygen saturations and heart rate improved. Bronchoscopy failed to demonstrate any evident pathology. However, computed tomography scan revealed a defect in the posterior wall of the trachea proximal to the termination of the endotracheal tube. Cardiothoracic surgery was consulted and performed a primary repair of the tracheal defect. The patient was extubated soon after surgery, and he was discharged home neurologically intact. CONCLUSIONS: The initial presentation of spontaneous tracheal rupture can be misleading and difficult to diagnose. After resuscitation, stabilization, and diagnosis, both surgical repair and nonoperative management have been reported as successful treatment measures for tracheal disruption.

Effect of race on the timing of the Glenn and Fontan procedures for single-ventricle congenital heart disease.

OBJECTIVE: Disparities in health care have been documented between different racial groups in the United States. We hypothesize that there will be racial variance in the timing of the Glenn and Fontan procedures for children with single-ventricle physiology. DESIGN AND SETTING: We performed a retrospective review of a national pediatric intensive care unit database (Virtual PICU Performance System, LLC). PATIENTS: Children with hypoplastic left heart syndrome, tricuspid atresia, and common ventricle, admitted from January 2006 to July 2008, were included. Data included race, weight, age, medical length of stay, Paediatric Index of Mortality 2 score, and survival. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 423 patients from 29 hospitals. The study population was 7.6% black, 13.0% Hispanic, 59.8% white, 9.2% "other," and 11.6% had missing racial/ethnic information. Diagnoses included 255 patients with hypoplastic left heart syndrome, 91 with tricuspid atresia, and 77 with common ventricle. The median age for the Glenn procedure (n = 205) was 5.5 months (interquartile range, 4.6-7.0 months) and 39.7 months (interquartile range, 32.4-50.6 months) for the Fontan procedure (n = 218). There was no difference between the median age at the time of the Glenn or Fontan procedures between the different racial/ethnic groups (p = .65 and p = .16, respectively). The medical length of intensive care unit stay for patients receiving the Glenn and Fontan procedures was 3.7 days (interquartile range, 1.9-6.1 days) and 3.7 days (interquartile range, 1.9-6.8 days), respectively. There were no differences in medical length of intensive care unit stay for the Glenn procedure between the different racial/ethnic groups (p = .21). Hispanic patients had a longer medical length of intensive care unit stay (6.3 days; interquartile range, 3.1-9.9 days) than white patients (2.9 days; interquartile range, 1.8-5.3 days) for the Fontan procedure (p = .008). CONCLUSION: The timing of single-ventricle palliative procedures was not affected by race/ethnicity.