Acute intoxication and poisoning in children: the experience of a tertiary-care hospital from 2001-2012

The frequency and distribution of acute intoxications and poisoning from non-pharmacological substances in children was evaluated in this observational-descriptive study. This was done by analyzing all admissions to the Emergency Room of our University in Rome during the period 1st January 2001 to 31st December 2012. We found 249 patients aged 0-14 years: 147 males and 102 females. The highest incidence occurred in the first 4 years of life: 44.2% in the 1-2 year age-group. Cases were mostly related to solvents (44.6%), natural products (17.7%), agricultural products (12.9%), corrosive acids and alkaline caustics (14.8%). Most admissions occurred during the time slot 18:00 to 21:00 (23.7%). No clinical symptoms were observed in 116 children (46.6% of the total), and physical examination was unrevealing. The remaining 133 displayed nausea/vomiting (22%) and pharyngeal hyperemia (18.8%). Laboratory tests and imaging studies were only performed in selected cases. In terms of consulting requests, the Poisons Center was contacted 156 times (62.6% of cases), the Pediatric Intensive Care Unit 38 times (15.2%), and the surgeon-endoscopist 18 times (7.2%). A short period of observation and monitoring in the Emergency Room was warranted in 106 children (42.5%). Gastroprotective drugs were used in 75 cases (30.1%) and activated charcoal in 18 (7.2%). Nintey-five children (38.2%) were admitted to the pediatric department , but no complications occurred. Targeted information programs in schools and during pediatric check-ups should decrease the risk of ingestion of non-pharmacological substances in children, and the costs of its management

Diluted porcine surfactant lung lavages in children with severe ARDS

Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis. Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) <150 . We used a diluted concentration of Curosurf (8 mg/ml) divided into 4 aliquots, for a total dose of 25 mg/kg. An additional aliquot was used for bronchoalveolar lavage before surfactant treatment. All children showed a dramatic response to surfactant with rapid and progressive increase in compliance and improvement of all respiratory mechanics. Mechanical ventilation settings were rapidly reduced and gas exchange improved with a PaO2/FiO2 >200 for more than 12 hours. Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment

Exogenous Surfactant Treatment in Children with ARDS

Since the Food and Drug Administration (FDA) approved exogenous surfactant in the early 90s for the treatment of neonates with Hyaline Membrane Disease (HMD), many studies have focused on enlarging its indications for others types of lung injuries and for other age groups. Although in the past 20 years no studies have shown clear results about the efficacy of exogenous surfactant treatment in paediatric Acute Respiratory Distress Syndrome (ARDS), many of them were able to point out and better define very important aspects of this treatment like dosage, timing, ways of administration and usage of different types of surfactant (natural and synthetic). In this review we retrace the development of studies looking at the role of exogenous surfactant treatment in paediatric ARDS

Diluted porcine surfactant lung lavages in children with severe ARDS

Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis. Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) <150 . We used a diluted concentration of Curosurf (8 mg/ml) divided into 4 aliquots, for a total dose of 25 mg/kg. An additional aliquot was used for bronchoalveolar lavage before surfactant treatment. All children showed a dramatic response to surfactant with rapid and progressive increase in compliance and improvement of all respiratory mechanics. Mechanical ventilation settings were rapidly reduced and gas exchange improved with a PaO2/FiO2 >200 for more than 12 hours. Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment

Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander?

We present the case of a 13 year old patient with myocardial bridge in left anterior descending coronary artery, who develops a myocardial infarction after a cardiothoracic trauma. About 24 hours after admission for trauma, an Electrocardiogram (ECG) showed an ST-segment elevation on anterior-lateral leads and QS complex referable to anterior-septal infarction, and an increase in troponin T serum levels was noted. An impaired left ventricular ejection fraction with diffuse regional wall motion abnormalities involving the left ventricular apex and interventricular septum were seen at transthoracic echocardiography. Contrast enhanced cardiac magnetic resonance showed a widespread myocardial edema and necrosis at the level of left ventricular apex and interventricular septum. Intramural hemorrhage and signs of microvascular damage were found mainly at the mid-ventricular level of the anteroseptal and anterior segments of myocardium. The coronary angiography revealed normal coronary arteries except for a myocardial bridge on distal part of left anterior descending coronary artery. A myocardial infarction with hemorrhage and microvascular damage was diagnosed, but the absence of a correspondence between site of the most severe myocardial injury and distal location of myocardial bridge was noted. Whether myocardial infarction and microvascular damage have been caused only by traumatic hit, or also by the contribution of myocardial bridge, is unknown. An intense constriction of left anterior descending coronary artery at the level of myocardial bridge could have determined thrombus formation with subsequent septal and distal embolization and myocardial infarction

Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander?

We present the case of a 13 year old patient with myocardial bridge in left anterior descending coronary artery, who develops a myocardial infarction after a cardiothoracic trauma. About 24 hours after admission for trauma, an Electrocardiogram (ECG) showed an ST-segment elevation on anterior-lateral leads and QS complex referable to anterior-septal infarction, and an increase in troponin T serum levels was noted. An impaired left ventricular ejection fraction with diffuse regional wall motion abnormalities involving the left ventricular apex and interventricular septum were seen at transthoracic echocardiography. Contrast enhanced cardiac magnetic resonance showed a widespread myocardial edema and necrosis at the level of left ventricular apex and interventricular septum. Intramural hemorrhage and signs of microvascular damage were found mainly at the mid-ventricular level of the anteroseptal and anterior segments of myocardium. The coronary angiography revealed normal coronary arteries except for a myocardial bridge on distal part of left anterior descending coronary artery. A myocardial infarction with hemorrhage and microvascular damage was diagnosed, but the absence of a correspondence between site of the most severe myocardial injury and distal location of myocardial bridge was noted. Whether myocardial infarction and microvascular damage have been caused only by traumatic hit, or also by the contribution of myocardial bridge, is unknown. An intense constriction of left anterior descending coronary artery at the level of myocardial bridge could have determined thrombus formation with subsequent septal and distal embolization and myocardial infarction

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Acute intoxication and poisoning in children: the experience of a tertiary-care hospital from 2001-2012

The frequency and distribution of acute intoxications and poisoning from non-pharmacological substances in children was evaluated in this observational-descriptive study. This was done by analyzing all admissions to the Emergency Room of our University in Rome during the period 1st January 2001 to 31st December 2012. We found 249 patients aged 0-14 years: 147 males and 102 females. The highest incidence occurred in the first 4 years of life: 44.2% in the 1-2 year age-group. Cases were mostly related to solvents (44.6%), natural products (17.7%), agricultural products (12.9%), corrosive acids and alkaline caustics (14.8%). Most admissions occurred during the time slot 18:00 to 21:00 (23.7%). No clinical symptoms were observed in 116 children (46.6% of the total), and physical examination was unrevealing. The remaining 133 displayed nausea/vomiting (22%) and pharyngeal hyperemia (18.8%). Laboratory tests and imaging studies were only performed in selected cases. In terms of consulting requests, the Poisons Center was contacted 156 times (62.6% of cases), the Pediatric Intensive Care Unit 38 times (15.2%), and the surgeon-endoscopist 18 times (7.2%). A short period of observation and monitoring in the Emergency Room was warranted in 106 children (42.5%). Gastroprotective drugs were used in 75 cases (30.1%) and activated charcoal in 18 (7.2%). Nintey-five children (38.2%) were admitted to the pediatric department , but no complications occurred. Targeted information programs in schools and during pediatric check-ups should decrease the risk of ingestion of non-pharmacological substances in children, and the costs of its management