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By: Rasheed Adebayo Gbadegesin, MBBS

• Professor of Pediatrics
• Professor in Medicine
• Affiliate of Duke Molecular Physiology Institute

https://medicine.duke.edu/faculty/rasheed-adebayo-gbadegesin-mbbs

Once a child is established in neonatal care treatment 002 cheap duricef 500 mg with amex, the situations in which the neonatal team would consider offering discontinuation of neonatal supportive care are described within the Royal College of Paediatrics and Child Health document medicine runny nose generic duricef 250mg otc, Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice symptoms gestational diabetes purchase duricef online. The ‘no chance’ situation: the child has such severe disease that life-sustaining treatment simply delays death without significant alleviation of suffering medicine hat order 500mg duricef visa. Although the child may be able to symptoms 5dpo buy duricef online pills survive with treatment treatment under eye bags buy duricef now, the degree of physical or mental impairment will be so great that it is unreasonable to expect them to bear it. The child and/or family feels that, in the face of progressive and irreversible illness, further treatment is more than can be borne. They wish to have a particular treatment withdrawn or to refuse further treatment, irrespective of the medical opinion that it may be of some benefit. The amended Abortion Act sets out the legal framework within which an abortion may be legally carried out and, in effect, creates a series of defences to prosecution under the former two Acts. G What constitutes a serious handicap becomes a particular issue for doctors when termi nation of pregnancy is likely to take place after 24 weeks of gestation, when abortion is no longer lawful under Ground 1(1)(a) of the Abortion Act. G Termination for fetal abnormality will only be lawful when two registered medical practi tioners are of the opinion, formed in good faith, that the grounds for termination of pregnancy are met; in the final analysis a jury would have to determine that these beliefs are appropriate on the totality of the evidence. G A fetus born alive after termination for a fetal abnormality is deemed to be a child and must be treated in his or her best interests and managed within published guidance for neonatal practice. A fetus born alive with abnormalities incompatible with long-term survival should be managed to maintain comfort and dignity during terminal care. Definition of substantial risk and serious handicap When a fetal abnormality has been detected, the pregnancy can be terminated before 24 weeks of gestation under Ground 1(1)(a) of the Abortion Act but after 24 weeks of gestation it can only be carried out if there is a substantial risk that the child if born would be seriously handi capped. Thus, much of the discussion around late termination of pregnancy for fetal anomalies has focussed on what constitutes a substantial risk of serious handicap. Substantial risk There is no legal definition of what comprises a ‘substantial’ risk. Whether a risk is substantial depends upon factors such as the nature and severity of the condition and the timing of diagnosis, as well as the likelihood of the event occurring. It has been argued that, since neither substantial risk nor serious handicap is defined, each can be interpreted on a largely subjective basis. As a result, it would be difficult if not impossible to demonstrate that a decision to terminate the pregnancy was not taken in good faith. The same commentator suggests that, if their mistake is not factual but rather whether the 25% is a ‘substantial’ risk, their ‘good faith’ will not protect them under the Act if a court takes the view that that is a misinterpretation of the Act. The view has been expressed that ‘provided the condition is not trivial, or readily correctable, or will merely lead to the child being disadvan taged, the law will allow doctors scope for determining the seriousness of a condition. At a minimum it is suggested a “serious handicap” would require the child to have physical or mental disability which would cause significant suffering or long-term impairment of their ability to function in society. The most serious genetic or other conditions which manifest themselves at birth or almost immediately thereafter are by and large likely to fall within the scope of Section 1(1)(d)’. The challenge was adjourned when the local police agreed to reinvestigate the case but this resulted in a decision from the West Mercia Chief Crown Prosecutor as follows: ‘I consider that both doctors concluded that there was a substantial risk of abnor malities that would amount to the child being seriously handicapped. The evidence shows that these two doctors did form this opinion and formed it in good faith. In these circumstances, I have decided there was insufficient evidence for a realistic prospect of conviction and there should be no charges against either of the 9 doctors. These include the following two categories: G assisted performance: the need for a helping hand; that is, the individual can perform the activity or sustain the behaviour, whether augmented by aids or not, only with some assistance from another person G dependent performance: complete dependence on the presence of another person; that is, the individual can perform the activity or sustain the behaviour but only when someone is with him or her most of the time. Our advice is that doctors should continue to weigh up the following factors when reaching a decision: G the potential for effective treatment, either in utero or after birth G on the part of the child, the probable degree of self-awareness and of ability to commu nicate with others G the suffering that would be experienced G the probability of being able to live alone and to be self-supportive as an adult G on the part of society, the extent to which actions performed by individuals without disability that are essential for health would have to be provided by others. These may not be obstetricians but may be specialists in the management of the particular condition. For example, in the case of cleft palate, the woman should be referred to the surgical team that specialises in its treatment. In other cases, the appropriate specialist may be a neonatologist, paediatrician or neurologist. If it is their opinion on which reliance is based, it may be appropriate for them to provide one of the signatures under the Act. A further issue unresolved by the law concerns the time when the handicap will manifest itself. Children born with a correctable congenital abnormality, such as diaphragmatic hernia, may be deemed to be seriously handicapped until they receive effective surgical treatment; others suffering from a genetic condition, such as Huntington’s disease, are unlikely to manifest the condition until later in life. The Working Party sees little reason to change the current law regarding the definition of serious abnormality and concludes that it would be unrealistic to produce a definitive list of conditions that constitute serious handicap. Firstly, sufficiently advanced diagnostic techniques capable of accurately defining abnormal ities or of predicting the seriousness of outcomes are not currently available. Secondly, the consequences of an abnormality are difficult to predict, not only for the fetus in terms of 10 viability or residual disability but also in relation to the impact in childhood as well as on the family into which the child would be born. Whether a risk will be a matter of substance may vary with the seriousness and consequences of the likely disability. G There is no legal definition of serious handicap – nor is it clear whether the disability has to be present at birth or will qualify if it is something that will afflict the child later in life. G the Working Party sees little reason to change the current law regarding the definition of serious abnormality and concludes that it would be unrealistic to produce a definitive list of conditions that constitute serious handicap. An assessment of the seriousness of a fetal abnormality should be considered on a case-by-case appraisal, taking into account all available clinical information. G In cases of doubt the Working Party recommends that obstetricians seek advice from maternal-fetal medicine specialists and where decision making is not straight forward, colleagues who specialise in treating the conditions in question, and in appropriate cases request them to counsel the parents. The diagnosis of fetal abnormality Since the previous guidance in 1996,1 antenatal screening for fetal abnormalities is more widespread, the performance of ultrasound in detecting fetal anomalies has improved and the natural history of many fetal anomalies is better understood. There is some evidence that the detection of trisomy 21 is occurring earlier in pregnancy. Detection of fetal abnormalities and assessment of risk of serious handicap the suspicion of a fetal abnormality may be suggested by a family history, for example, of cystic fibrosis. Alternatively, an abnormality may be detected by chance when a routine scan is performed for another reason; for example, because of concerns about fetal growth or clinical suspicion of hydramnios. Most fetal abnormalities are detected as a result of routine screening for trisomy 21 and ultrasound screening for major structural abnormalities, such as neural tube defects. The first is an early scan, undertaken after 8 weeks of gestation for dating the pregnancy and confirming viability and, increasingly, screening for trisomy 21; gross fetal abnormalities may also be detected. The second scan undertaken between 18+0 and 20+6 weeks of pregnancy is to detect major structural anomalies. The objectives of this ultrasound scan are two-fold: first, to identify abnormalities associated with severe morbidity or that are incompatible with life, so that women and their partners can be offered a choice, within the constraints of the law, as to whether or not to have the pregnancy terminated; second, to detect abnormalities which require early intervention following delivery or which may benefit, in a small number of cases, from intrauterine treatment. The use of ultrasound to screen for fetal abnormalities at 18+0–20+6 weeks results in variable detection rates, depending on the type of abnormality. Although the literature largely focuses on missed lesions, it is the certainty of diagnosis that is important for determining prognosis and providing critical information to women and their partners confronted by a decision of whether or not to have the pregnancy terminated. Prognosis An accurate diagnosis is needed for the severity of the condition to be assessed and the prognosis determined. This is reasonably clear-cut when the condition is deemed fatal and many such conditions will be identified before 22 weeks. It is when the anomaly is more likely to result in morbidity than mortality that problems in defining severity arise. To acquire better outcome information on infants with specific congenital abnormalities, routine follow-up is required, such as the 2-year data collection recommended for premature infants. This is because of the small numbers recorded in each category: if the number is fewer than ten (including zero), information is not made available because of confidentiality concerns that individual women or health professionals may be identifiable. This may mean that decisions based on optimal information cannot be made before 24 weeks of gestation. In 2008, one third of terminations undertaken beyond 24 weeks were for abnormalities of the central nervous system (42/124). This is likely to reflect the greater certainty that the abnormality 14 would result in serious handicap. Severe cardiac abnormalities Severe cardiac abnormalities have a reasonably predictable outcome. Once an abnormality has been identified, paediatric cardiologists can offer fairly accurate information on whether the anomaly can be corrected (to normal anatomy) or whether a palliative procedure is required, with the much greater risk of long term morbidity. Renal abnormalities Renal abnormalities can present late in pregnancy with severe oligohydramnios. Occasionally, biochemical testing of fetal urine can point to renal impairment but the accuracy of prediction is problematic and testing is not possible in the absence of a dilated urinary tract. Musculoskeletal abnormalities Musculoskeletal abnormalities can pose particular diagnostic and counselling problems. Although many skeletal abnormalities are lethal, isolated absent or abnormal limbs and other skeletal dysplasias, such as achondroplasia, are often shocking to parents but not always associated with ‘severe’ handicap. There were fewer than ten late terminations in the muscu loskeletal group in 2008 and 58 in the 6-year period 2003–2008. Other structural abnormalities Other structural abnormalities, such as facial clefting, can be distressing for parents. Whereas isolated cleft lips can usually be repaired with minimal long-term consequences, combined cleft palate and lip can be more problematic. Chromosomal abnormalities Chromosomal abnormalities detected at amniocentesis or chorionic villus sampling are usually diagnosed and decisions made by 24 weeks. However, late diagnosis may arise following either late booking or late manifestation of clinical features arising from an underlying abnormality such as hydramnios in duodenal atresia (associated with trisomy 21) or fetal growth restriction (associated with trisomy 18). A fetus with a structural abnormality associated with a chromosome abnormality is likely to have a poorer prognosis. For example, the decision to terminate a fetus with a severe isolated limb abnormality after 24 weeks clearly raises greater dilemmas than termination at an earlier stage of pregnancy. This may be due to earlier diagnosis, the availability of better diagnostic and prognostic information (in some cases from fetal magnetic resonance imaging) and/or a more conservative approach to pregnancy termination after 24 weeks of gestation. Conversely, there seems to be an increase in terminations for cardiac abnormalities, probably reflecting the increasing emphasis on ultrasound screening for cardiac abnormalities and improving expertise in diagnostic fetal echocardiography. Conclusions G the suspicion of an abnormality may arise as a result of fetal anomaly screening, by chance at the time of a scan carried out for clinical reasons or because there is a known family history. G A woman with findings suggesting a fetal anomaly should be referred to a person or centre with expertise in fetal medicine. Units without a fetal medicine specialist should refer women to the nearest unit with fetal medicine expertise. It is therefore recommended that these programmes are linked to systems which aim to provide continuous monitoring of the frequency, nature and outcomes of congenital anomalies in live or stillborn infants and fetuses in England, Scotland and Wales. An appro priately funded and centrally coordinated system of congenital anomaly ascertainment that covers all parts of the country is essential. G Outcome data on children born with specific abnormalities are required to provide better 16 information on natural history and prognosis. These data would enable a more accurate assignment of prognosis and better informed prenatal counselling in the future. The Working Party recommends that the envisaged 2-year data collection for preterm infants should be expanded to collect outcome data for infants with abnormalities. G Abortion statistics for England and Wales for 2008 report that 124 terminations for fetal anomalies (Ground E) were performed over 24 weeks of gestation. As numbers in most categories of abnormality were fewer than ten, the nature of the abnormalities is not disclosed and trends or patterns in termination cannot be determined. We recommend that such information is published in the Department of Health Abortion Statistics on a 3 and 6-year cycle. Technological and other developments in the diagnosis of fetal abnormalities There have been a number of developments in the detection of congenital abnormalities in the last 10 years of potential relevance to the timing of and indication for termination of pregnancy. Earlier diagnosis Recent research has focused on the diagnosis of fetal abnormalities at an earlier gestation. While some structural abnormalities will be detected early, it remains the case that the majority will only be identified on an anomaly scan at 18+0 to 20+6 weeks. Early diagnosis has potential benefits: termination is safer the earlier it is performed and there may be greater access to surgical termination, which some women prefer. Improved diagnosis Two-dimensional (2-D) ultrasonography remains the mainstay of noninvasive fetal diagnosis. However, new imaging modalities can provide additional information although in many cases this will not necessarily lead to a more certain diagnosis. The capability to produce three-dimensional (3-D) images is becoming a standard feature on many new ultrasound machines, although its precise role remains controversial. What is clear is that, for some abnormalities, particularly those involving external structures (most notably the face), 3-D imaging can sometimes be helpful for counselling, as the parents can more easily understand a 3-D than a 2-D image and hence may be in a better position to appreciate the physical impact of the abnormality. However, as the small number of studies assessing the ability of 3-D imaging to detect fetal abnormality compared with 2-D imaging have found no added benefit (and some abnormalities were missed or misdiagnosed),19,20 it is unlikely that 3-D ultrasound will become the main fetal imaging modality. As a complement to 2-D imaging, there are data suggesting that 3-D contributes useful information concerning skeletal dysplasia, abnormalities of the extremities and face, the assessment of organ volume and in the determination of the upper level of bony abnormality in spina bifida. The development of magnetic resonance sequences to allow rapid image acquisition has reduced movement artefact and meant that detailed images of the fetus can be obtained. Natural history of fetal abnormalities Information from improved imaging and from postnatal follow-up studies has led to a greater understanding of the natural history of many fetal abnormalities permitting a more accurate assignment of prognosis for some fetal defects and better informed parental counselling. A factor contributing to the improved understanding of prognosis has been the multidisciplinary approach to clinical management and counselling. In many units, parents will receive infor mation not only from consultants with a special interest in fetal medicine, midwives and neonatologists but also, when relevant, from paediatric surgeons, neurologists, cardiologists and geneticists. Technological advances mean that it is possible to diagnose some aneuploidies such as trisomy 21, within 24–48 hours using the polymerase chain reaction or fluorescence in situ hybridisation. In the future, it seems likely that techniques involving rapid assessment of the whole genome, such as array comparative genomic hybridisation, will greatly increase the amount of information that can be obtained from a single sample but this raises concerns about false positive rates and counselling parents with newly detected submicroscopic chromosomal imbalances.

Mixed porphyrias with the possibility of both acute attacks and cutaneous lesions treatment 4 addiction best purchase duricef. Pathogenesis Reactive oxygen species symptoms for mono purchase 250 mg duricef amex, infammatory mediators symptoms 9 weeks pregnancy buy duricef 250mg without prescription, and infammatory cells have been shown to treatment quad tendonitis generic 500mg duricef visa contrib ute to symptoms nausea dizziness cheap duricef 500mg mastercard the development of cutaneous lesions in porphyrias treatment 20 nail dystrophy duricef 250mg generic. Cutaneous Porphyrias Dermatological manifestations of cutaneous porphyrias appear in two different forms. Despite these differences, clinical manifestations are identical in all three forms. Nail alterations: Minimal trauma may cause the formation of vesiculobullous lesions under the nail plates. Scleroderma-like lesions could develop mainly in adulthood after a long evolution of the disease, particularly on the head, neck, and scalp. Chloroquine, at a weekly dosage of 3 mg/kg divided in 2 nonconsecutive days, is usually effective and well tolerated by the children. Autosomal dominant inheritance with variable expressivity and incom plete penetrance has been considered. Nail alterations are not very common; however, mild-to-moderate nail plate dystrophies and photo-onycholysis may appear if sun exposure is not avoided. Progressively, by repetition of acute outbreaks, the skin of the exposed areas becomes thickened and yellowish. The presence of deep wrinkles in the nasolabial folds, below the lower eyelids, transversely over the nose and around the mouth, is characteristic. On the dorsa of the hands, the skin of the knuckle is characteristically thickened with deep folds (Figure 12. The biopsy of chronic cutaneous lesions, particularly of the skin of dorsa of hands, fn gers, and facial lesions, shows the presence of dense eosinophilic homogeneous hyaline deposits, initially perivascular, and very characteristic. However, the common sunscreen is not use ful because it protects the skin from the sunburn band (290–320 nm) but not from longer wavelengths that are particularly harmful in these patients (400–410 nm or even longer). This may occur where clinical manifestations appear exclusively in the homozygous state (the autosomal recessive porphyrias). The onset of the disease occurs in infancy and is characterized by cutaneous hyperfragility and photosensitivity. Children develop post-traumatic or light-induced vesiculobullous lesions that evolve into erosions and scars on uncovered areas, especially the face and hands. Hypertrichosis is also a prominent and a constant feature on the light-exposed skin, such as the face and limbs. Progressively, the skin of exposed regions (face and hands) becomes hard and pigmented. These alterations produce severe mutilations of the cen trofacial area, especially the mouth and nose, as well as of the hands. Nail alterations: Sclerodactyly and nail dystrophy develop on the hands, with an eventual progressive loss of the terminal phalanges and fnger nails (Figures 12. There is also the possibility of the preserva tion of fngers and nails, if they are continuously protected by gloves. However, the gravity of evolution and mutilations is variable, depending on individual genotype and phenotype characteristics. Other noncutaneous manifestations may include ocular alterations such as photophobia, excessive tearing, keratoconjunctivitis, loss of eyelashes, ectropion, and a scleroconjunctival nonpainful ulcer (scleromalacia perforans). A distinctive osteodystrophy, with osteolysis of light-exposed extremities and high turnover osteoporosis, may develop. In one clinical series, the “classic” patients with severe disease were noted to be homozygous for a single mutation (C73R, a cystine-to-arginine substitution at position 73). The urine is dark and progressive hypertrichosis, scleroderma, and ocular lesions are noted. Treatment of chronic hepatitis with boceprevir leads to remission of porphyria cutanea tarda. Uroporphyrinogen-decarboxylase defciencies: Porphyria cutanea tarda and related conditions. Seasonal palmar keratoderma in erythropoietic protopor phyria indicates autosomal recessive inheritance. Correction of uroporphyrinogen decarboxylase def ciency (hepatoerythropoietic porphyria) in Epstein–Barr virus-transformed B-cell lines by retrovirus mediated gene transfer: Fluorescence-based selection of transduced cells. Hepatoerythropoietic porphyria: A new uroporphyrinogen decar boxylase defect or homozygous porphyria cutanea tarda Frequency Melanonychia is rare in fair-skinned children but is a relatively common condition in individuals with dark complexion. However, the exact percentages of melanonychia in general and particularly in children are not known. Most brown nail streaks develop between the age of 6 months and 5 years, but later appearance is not uncommon. Etiology Melanocytes are present in the nail, but more in the matrix than in the nail bed. Functional hypermelanosis, lentigines, and nevi are the most frequent causes of melanonychia, with ungual melanoma being exceedingly rare in children. A homo geneous brown streak is visible in addition to the postbiopsy nail dystrophy. Re-excision by the tangential biopsy method remained without a recurrence after 3 years. However, there are some examples of subungual nevi localized both in the matrix and in the nail bed and they give rise to longitudinal melanonychia. Melanonychia develops when the matrix keratinocytes are unable to disintegrate the excess melanin in the matrix. The melanin is transferred into matrix keratinocytes that migrate obliquely upward and distally during nail plate genesis. Since a lentigo is probably the frst stage of nevus development, this can be estimated to be true also for matrix lentigines. Sometimes the streak is so light that it is barely visible, sometimes it is virtually black. The darker pigmentation of the proximal nail fold skin is a common feature in dark-skinned individuals and should not be confused with Hutchinson’s sign. Longitudinal melanonychias always run from the matrix into the free margin of the nail as the melanin is incorporated in the nail substance. The melanin cannot be scraped off like superfcial and exogenous pigmentations caused by certain bacteria and stains. Dermatoscopy of the free end of the nail plate usu ally allows the melanin within the nail plate to be localized. Pigment in the entire nail thickness indicates active melanocytes in the entire length of the matrix. Melanonychia 173 Histopathology Depending on the material available for histopathological examination, different alterations are seen. In the nail clippings, particularly when the streak is only light brown, hematoxylin and eosin (H&E) stained sections often do not exhibit a clear-cut melanin pigmentation. However, Fontana–Masson stain usually shows melanin granules in the nail plate, which is not seen in normal nails. Melanin is commonly seen in H&E sections of melanonychias due to lentigines and nevi, and occasionally, the latter may also show an intraungual nevus cell nest. Depending on the width of the brown band, a punch with a maximal diameter of 3 mm, a transversely oriented fusiform, or a slightly crescentic matrix biopsy, and in the case of lateral localization a lateral longitudinal nail biopsy or, particularly for wider melanonychias, a tangential excisional biopsy is preferred. This nail may be laid back after the biopsy and fxed with a suture strip or one or two stitches, which facilitates wound healing. The specimen should be marked to allow it to be oriented in the histopathology laboratory. Functional melanonychia exhibits just an increase of melanin granules with a normal melanocyte count, which is about 6. The discrepancy between a normal H&E stain and normal immunohistochemistry on one side and the increased pigmentation seen in the argentaffn reaction of Fontana–Masson allows the diagnosis of functional melanonychia to be made. In contrast to normal matrix melanocytes that are frequently localized above the basal row of matrix keratinocytes, melanocytes in lentigines often mainly occupy the basal layer. The melanocyte nests of a nevus are usually oval and may sometimes be taken up with the maturing cells of the keratogenous zone to fnally be included in the nail plate (Figure 13. The degree of pigmentation varies from light brown to almost black; the color intensity does not refect the dignity of the lesion. However, a very large congenital blue nevus involving the entire big toenail and periungual tissue was observed with the so-called benign lymph node metastasis. However, particularly in Japanese subjects, periungual pigmentation has also been observed in benign longitudinal melanonychia23,24 and it is not uncommon in congenital melanocytic nevi of the nail. Dermatoscopy gives little more accuracy, although criteria like background color, evenness of striation, regular distance of striae within the band, and micro-Hutchinson sign are more easily evaluated. Congenital nevi may give rise to very dark and wide bands, often associated with nevus spread to a part of the surrounding periungual skin; this periungual pigmentation is not suspicious of melanoma. Fumagoid bodies (Medlar bodies) were once seen to cause longitudinal melanonychia. Staining from enterobacteria is usu ally on the nail surface and can be scraped off as can many other exogenous discolorations. Nail clippings may contain nests of nevus cells but intraungual single melanocytes are considered to be melanoma cells. Hematomas are not included in the free margin of the nail plate and their entire appearance is different; it is easy to differentiate them from melanin pigmentation. Natural Course the natural course of longitudinal melanonychias has not been systematically studied. Parents present ing their child with a brown streak in the nail are either worried about the prognosis or embarrassed because of the unusual cosmetic appearance. Treatment of Nail Lentigines and Nevi Whereas it is our policy to remove acquired lentigines and nevi of the nail whenever the patient or his or her parents are concerned, many patients try to avoid surgery and instead rely on conservative diag nostic measures such as dermatoscopy or laser scanning microscopy. Even when a light brown streak reoccurs, the histopathologic diagnosis has been made with certainty. It is not the lack of examination tools but the lack of awareness of potential malignant development that delays the diagnosis of ungual melanomas. Certainly, more precise criteria for the diagnosis of matrix lentigines and nevi will be developed and the 178 Pediatric Nail Disorders refnement of confocal laser scanning microscopy criteria will enable us to differentiate, at least in many cases, lentigines from nevi and above all from subungual melanoma. A rapidly growing pigmented nail streak resulting in diffuse mela nosis of the nail. Subungual melanoma in situ in a Hispanic girl treated with functional resection and reconstruction with onychocutaneous toe free fap. Consenso sobre dermatoscopia da placa ungueal em melanoniquias [Consensus on melanonychia nail plate dermoscopy]. Early malignant melanoma manifested as longitudinal melanonychia: Subungual mela noma may arise from suprabasal melanocytes. Two cases of unusual acral melanocytic tumors: Illustration of molecular cytogenetics as a diagnostic tool. Longitudinal melanonychia of the toenails with presence of Medlar bodies on biopsy. Several concordant meta-analysis proved that dermoscopy, performed by suffciently trained observers, enhances the diagnostic performances of cutaneous nevi, melanomas, pigmented basal cell carcinomas, dermatofbromas, thrombotized angiomas, and seborrheic keratosis. At this age, the main diagnostic dilemma is to diagnose nevi and exceptional (and, in several published cases, diagnostically debatable) cases of melanoma and to offer a reinsuring management of the longitudinal pigmented band to worried parents, once it is diagnosed in their child’s nail. To date, no single case of undebatable histopathology-proven melanoma has been observed in this cohort recruited from more than 40 different countries. Yet, in most cases, they stay in place through all ages and constitute the major part of nevi observed in elderly patients. Recent studies have shown that the major part of nevus-associated melanomas could be associated with this peculiar type of nevi. Extrapolation of the natural history of the congenital-type nevi of the skin to their nail-unit counterparts indeed raises the question of possible malignant evolution of a proportion of the nail located ones. Unfortunately, all but one of these criteria are com monly observed in congenital nevi of the nail unit. Clinical features of adult’s criteria for a malignant pigmentation are therefore frequently observed and constitute a major diagnostic pitfall. It augments the negative gestalt of the lesion in pediatric and unspecialized dermatologic clinics. Surgery is often the source of complicated evolution: not only defnitive functionally and signifcantly scarring but also recurrent Dermoscopy in Pediatric Longitudinal Nail Pigmentation 183 pigmentation which is then extremely diffcult to manage since anatomical changes led to diffcult-to diagnose pigmentation changes. In adults, it is considered as highly indicative of national register of congenital or nearly congenital nail malignancy. Periungual pigmenta tion (Hutchinson’s sign) is a clinical sign in favor of melanoma as described above. Yet this pigmentation might not be seen with the naked eye and only disclosed with the dermoscope. In contrast, in nevi, even in newborn or prepubertal children, the perinungual pigmentation reproduces the benign features described on acral skin that are parallel furrow pattern (Figure 14. In our experience, the fbrillar distal pigmentation is composed of thin longitudinal parallel lines in the periungual area in distality of the hyponychium (Figures 14. Reinsuring Evolutive Behavior of Congenital Nevi of the Nail Unit As seen previously, with the remarkable exception of the highly signifcant presence of a distal fbrillar pattern, neither the clinical features nor the dermoscopical observations of congenital nevi are specifc. Therefore, it is often impossible to rely only on one single observation to establish the diagnosis.

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All of these remain research tools medications rights buy line duricef, however treatment of scabies buy discount duricef 250 mg on-line, but may ultimately improve the predictive value of prenatal testing medications known to cause pancreatitis cheapest duricef. Current reported survival rates are on average around 50% medicine 1950 cheap duricef 500mg without prescription, yet there is a signifcant impact of gestational age at delivery medications 101 purchase 500 mg duricef fast delivery. Neither did they fnd a diference in mortality between vaginal and 16 cesarean delivery treatment myasthenia gravis cheap 250 mg duricef overnight delivery. Recommendations (prenatal management and delivery) – Following prenatal diagnosis, disease severity should be assessed at an experienced center. Delivery room management and treatment in the initial postnatal phase Initial treatment and procedures in the delivery room are based on the updated Guide lines of the International Consensus on Cardiopulmonary Resuscitation and Emergency 17 Cardiovascular Care Science with Treatment Recommendations. Monitoring and goal of treatment Measurements of heart rate, pre and postductal saturations, and intra-arterial blood pressure are recommended. The key principles are the avoidance of high airway pres sures and the establishment of adequate perfusion and oxygenation (based on preduc tal arterial saturation, SpO2 measurements). Based on expert opinion, the consortium agreed on preductal SpO2 boundaries in the delivery room of 80-95%. In the frst 2 hours after birth, preductal SpO2 levels as low as 70% are acceptable if they are improving without ventilator changes, if organ perfusion is satisfactory, as indicated by a pH > 7. Thus, to avoid hyperoxia, supplemental oxygen should be diminished by reducing the oxygen fraction when preductal saturation exceeds 95%. However, based on expert opinion, in those 176 • Chapter 10 infants who are predicted to have good lung development based on their prenatal as sessment. Low peak pres sures, preferably <25cm H2O, are recommended to avoid lung damage to the ipsilateral and contralateral lung. In 166 infants Caldwell and Watterberg found that premedication for intubation signifcantly attenuated both the clinical pain score and the increase in blood glucose as 22 marker of acute stress. Moreover, it seems that intubation success rates progressively improve with premedication, although in some cases this is not possible due to a lack 23 of vascular access. Naso or orogastric tube the consortium recommends immediate placing an oro or nasogastric tube with continuous or intermittent suctioning in order to prevent bowel distension and any additional ipsilateral lung compression. Vascular access As preductal PaO2 measurements refect the delivered oxygen to the brain, the arterial line should preferably be inserted into the right radial artery, also for blood sampling and monitoring of the arterial blood pressure. This is less desirable, however, than a right radial artery line because it refects the postductal situation, but on the other hand, it may give more secure longer term arterial access. It is important, however, to prevent further agitation from recurrent insertion attempts as 25 this may impair postnatal adaptation. Blood pressure control Measures to increase the systemic blood pressure may minimize the right-to-left shunt ing. However, there is no need to increase blood pressure levels to supranormal values if the preductal saturation remains above 80%. Therefore, the consortium recommends maintaining arterial blood pressure at normal levels for gestational age if preductal saturations remain between 80 and 95%. If tissue perfusion and blood pressure do not improve, inotropic and/ or vasopressor medication should be considered according to local practice. Hydrocortisone may be used in the early phase for the treatment of hypotension after 26 other treatment has failed. Recommendations – After delivery, the infant should be intubated routinely without bag and mask venti lation (grade of recommendation = D). In the frst 2 178 • Chapter 10 hours after birth, preductal SpO2 levels as low as 70% are acceptable provided they are slowly improving and organ perfusion is satisfactory (indicated by a pH >7. In individual cases, however, levels down to 80% may be accepted, providing organs are well perfused, as indicated by a pH >7. Oxygen toxicity can be avoided by decreasing FiO2 on the guidance of the saturation levels described above. Recommendations for initial ventilation settings for pressure-controlled ventilation are summarized below. Chest radiograph To assess the patient’s initial condition, a chest radiograph should be obtained as soon as possible. Recommendations – Conventional mechanical ventilation is the optimal initial ventilation strategy (grade of recommendation = C). Infants should remain sedated during me chanical ventilation until weaning form mechanical ventilation is commenced. A head ultrasound scan should be performed at a time when there is little danger of arousing the newborn. Careful monitoring of the blood pressure is then warranted because more fuid volumes or vasoactive drugs may be needed in view of the potential adverse hemodynamic efect of sedatives, in particular midazolam. Supportive care such as cocooning and swaddling is recommended to prevent stress from too much noise, light and nociceptive stimula tion. Hemodynamic management Hemodynamic management should be aimed at achieving appropriate end-organ perfusion determined by heart rate, urine output, and lactate levels. Echocardiography is indicated if there are signs of poor perfusion or if the blood pressure is below the normal level for gestation with a preductal saturation below 80%. This may show whether the poor perfusion is due to hypovolemia or myocardial dysfunction. Recommendations – Infants should be sedated and be monitored using validated analgesia and sedation scoring systems (grade of recommendation = D). Pulmonary hypertension A 2D echocardiography performed within the frst 24 hours after birth remains the best modality to 1) rule out the presence of cardiac anomalies; 2) assess the right heart function; and 3) determine the amount of pulmonary hypertension classifed accord 37,38 ingly (less or more than 2/3 systemic blood pressure). Especially in severe cases of pulmonary hypertension, a cardiac ultrasound may help to evaluate right ventricular dysfunction and/or right ventricular overload, which condition can also lead to left 39 ventricular dysfunction. There is no evidence for the usefulness of increasing systemic vascular resistance to treat right-to-left shunting, but a number of centers from the consortium suggest using inotropic or vasopressor agents such as dopamine, dobutamine and (nor)epinephrine 40 to maintain blood pressure at normal levels for gestation. If preductal saturation falls below 85% and/ or if there are signs of poor organ perfusion, treatment of pulmonary hypertension should be initiated. The efects of treatment may be best ad 46 dressed by repeated cardiac evaluation. This can lead to insufcient flling of the left ventricle and thereby to poor systemic perfusion. Re-opening of the ductus arteriosus with prostaglandin E1 may protect the right ventricle from excessive overload due to 47 increased afterload. Recommendations – Perform echocardiography within the frst 24 hours after birth to rule out structural cardiac anomalies (grade of recommendation = D). The routine use of a chest tube postoperatively to drain the efusion flling the pleural cavity has been abandoned. This does not preclude its use in individual cases to drain an efusion that is symptomatic, for example due to chylothorax existing before surgery. Minimal access surgery is 56 gaining ground on the open approach (thoracotomy or laparotomy). Minimal access surgery has esthetic advantages and may be performed in patients with a left-sided 56,57 defect and liver down, but carries a signifcantly higher risk of recurrence. To allow for better comparison of patient groups between studies it is recommended to 37 record the diaphragmatic defect size in all surgeries. Parenteral nutrition only is allowed until surgical repair and until postoperative enteral feeding has been achieved. Gastroesophageal refux may be treated both by antirefux medication and 61 by surgical intervention. Diuretics should be given in the case of persisting positive fuid balance without hypovolemia, aiming for 63 diuresis of >1 mL/kg/hour. Although it is eminence based medicine and many recommendations are level D, we think that a consensus of 184 • Chapter 10 many specialized centers on the use of a standardized treatment protocol will contribute to making more valid comparisons of patient data in ongoing and future multicenter prospective clinical studies. Clinical char acteristics and outcomes of patients with right congenital diaphragmatic hernia: A population based study. Infuence of location of delivery on outcome in neonates with congenital diaphragmatic hernia. Efect of hospi tal case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network. Prenatal interventions for congenital diaphragmatic hernia for improving outcomes. Predictors of the need for ex tracorporeal membrane oxygenation and survival in congenital diaphragmatic hernia: a center’s 10-year experience. Perinatal management of congenital diaphragmatic hernia: when and how should babies be delivered Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Efect of premedication regimen on infant pain and stress response to endotracheal intubation. Impact of premedication on neonatal intubations by pediatric and neonatal trainees. Neuromuscular blockade and lung function during resuscitation of infants with congenital diaphragmatic hernia. The mechanisms of pain-induced pulmonary vasocon striction: an experimental study in fetal lambs. Permissive hypercapnia in the manage ment of congenital diaphragmatic hernia: our institutional experience. Development of heart and respiratory rate percentile curves for hospitalized children. Assessment of right ventricular function using tissue Doppler imag ing in infants with pulmonary hypertension. Right ventricular diastolic function measured by tissue Doppler imaging predicts early outcome in congenital diaphragmatic hernia. Normative blood pressure data in non-ventilated prema ture neonates from 28-36 weeks gestation. A randomized trial of early versus standard inhaled nitric oxide therapy in term and near-term newborn infants with hypoxic respiratory failure. Efect of initial nitric oxide concentration on outcome in infants with persistent pulmonary hypertension of the newborn. A comparison of magnesium sulphate and sildenafl in the treatment of the newborns with persistent pulmonary hypertension: a randomized controlled trial. Persistence of pulmonary hypertension by echocardiography predicts short-term outcomes in congenital diaphragmatic hernia. Impact of hospital volume on in-hospital mortality of infants undergoing repair of congenital diaphragmatic hernia. Case Volume and Outcomes of Congenital Diaphragmatic Hernia Surgery in Academic Medical Centers. Optimal timing of congenital diaphragmatic hernia repair in infants on extracorporeal membrane oxygenation. Minimal access surgery for repair of congenital diaphragmatic hernia: is it advantageous Hypercapnia and acidosis during the thoracoscopic repair of oesophageal atresia and congenital diaphragmatic hernia. Antirefux surgery after congenital diaphragmatic hernia repair: a plea for a tailored approach. Preventive antirefux surgery in neonates with congenital diaphragmatic hernia: a single-blinded prospective study. Clinical pharmacology of the loop diuretics furosemide and bumetanide in neonates and infants. Neuromuscular blocking agents should be avoided if Unchanged (however in 2010, this recommendation possible* was presented in a separate section). If symptoms of poor perfusion and/or blood pressure Unchanged below the normal level for gestational age occur and are associated with preductal saturation below 80%, echocardiographic assessment should be performed* In case of hypovolemia, isotonic fuid therapy 10-20 In case of hypovolemia, fuid therapy (10-20 ml/ ml/kg NaCl 0. D Evidence level 3 or 4, or extrapolated evidence from studies rated as 2+ Part iV outcome Chapter 11 Neurodevelopmental outcome in high-risk congenital diaphragmatic hernia patients: An appeal for international standardization Kitty G. Snoek, Irma Capolupo, Annabella Braguglia, Lucia Aite, Joost van Rosmalen, Laura Valfre, Rene M. Longer length of hospital stay (LoS) was associ ated with worse cognitive outcome and motor function; LoS, low socioeconomic status, and ethnicity were associated with lower cognition. Due to diferences in outcomes between centers, careful interpre tation is needed before conclusions can be drawn for other centers. Future multicenter collaboration should not only focus on standardization of postnatal care, but also on international standardization of follow-up to identify risk factors and thereby reduce morbidity. It is a life-threatening disease caused mainly by persistent pulmonary hypertension and 1 pulmonary hypoplasia. The mortality rate 2 has decreased from 33 to 12% since this protocol was implemented. While most follow-up studies have focused on morbidity, few have examined neurodevelopment. Most of those studies 8-10 were cross-sectionally performed in small series in single centers. To date, no published studies have examined neurodevelopmental outcome after implementation of a standardized treatment protocol in a multicenter setting. As standard of care, survivors were ofered 11 a structured, longitudinal follow-up program, initiated in Rotterdam in 1999 and in 12 Rome in 2004. We evaluated prospectively collected data of repeated measurements at corrected ages of 12 and 24 months.

It may treatment junctional rhythm order 500mg duricef with visa, however medicine journey generic duricef 250 mg online, be hard for families to symptoms 9dp5dt buy duricef withdraw life support once it has been initiated xanax medications for anxiety buy duricef 250 mg online. These cases among others have set precedence on Autonomy Patient has the right tho choose or refuse their treatment current ethical standards in the clinical practice medications zanaflex discount duricef 500 mg mastercard. Bene cience Providers deliver care which is in the best interest of the patient Prior to medications ok for dogs purchase duricef 500mg with visa life sustaining therapy being withdrawn, there are several considerations that Non-male cence In providing care, do no harm to the patient should be addressed. The family needs to be informed about what to expect, whether Justice Providing “fair” care such as allocating resources equally or sys that be irregular breathing if taken off of the ventilator or a slower wasting if nutritional tematically among patients 26 support is withdrawn. It should be emphasized that pain relief will be a primary consid exam is suf cient. The criteria for brain death can either be made by clinical exam, see eration and a plan for narcotics or sedatives/anxiolytic agents should be available. However, according to the 2010 update on determining brain death in adults, there is In many institutions, there are protocols established to guide withdrawal of life sup currently insuf cient evidence to demonstrate if ancillary tests can accurately determine port in the most humane way. You need to familiarize yourself with your individual hospital policies and is withdrawn is dif cult to predict. Brain death will cause several pathophysiologic responses and a donor may need to be supported to maintain perfusion and viability of transplantable organs. This may Additionally, the family should be prepared emotionally for the dying process. In some include maintaining hemodynamic stability, administering uid, medications or vasoac facilities a palliative care service should be involved as emotional and psychological tive agents, and maintaining normothermia. While fatal arrhythmias do occur, systemic support and aid in the bereavement process. Clergy and social work should also be hypotension is the most common issue in brain death donors. Efforts should be made to contact endocrine-hypothalamic-pituitary dysfunction, which may manifest as diabetes insipi anyone who would have an interest in seeing the patient prior to withdrawal of life sup dus, hypoglycemia or hypothermia. Organ donation after cardiac death involves withdrawal of life-sustaining therapies in Documentation in the process is also important and a do-not-resuscitate order should be or near the operating room setting. This order will detail what is and is not desired by the family in caring for the patient. This can include the decision to withhold vasoactive medications for blood Table 6. Finding Explanation Unresponsiveness/Coma Absence of spontaneous or elicited motor activity. Donated organs can be recovered after the patient meets criteria for heart rate to noxious stimulus in all ex brain death or cardiac death. Apnea Draw an arterial blood gas prior to dis connect from ventilator, which must show the de nition of brain death is the irreversible loss of brain functioning. Reversible conditions such as electrolyte imbalances, acid-base disorders, drug blood pressure cuff/arterial line, and elec intoxication, anesthetic agents, endocrine disturbances, and hypothermia need to be trocardiography. Ad Disconnect from ventilator and provide ditionally, there should be absence of high spinal cord injuries, neuromuscular diseases, oxygen ow through endotracheal tube of 4-10 liters/minute. Test can take as There are speci c diagnostic criteria for brain death and these include unresponsive long as 15 minutes if there is no respiratory ness, absence of autonomic re exes, absence of brainstem re exes, and apnea. In the effort, no hypotension (<90 mmHg) or United States, rules for determining brain death vary by state and individual hospital desaturation (SaO <90%). Typically two separate physicians, usually in the elds of Neurology, Neurosur Apnea test is positive if: gery, Internal medicine, Pediatrics, or Anesthesiology, need to agree upon brain death No respiratory movements and sometimes these exams must be a designated number of hours apart, i. If the family chooses to be present, life support will usually be withdrawn in an induction room where the family may say goodbye after Questions death. A patient is pronounced dead if after ve minutes there is an absence of circula tion (pulselessness), along with apnea, unresponsiveness, and asystole on electrocar 6. Once death is certi ed, the patient is moved to the operating room where she wishes to spend the rest of her days at home with her family. No organs can be procured until a physician who is not of the four principles of medical ethics He did not have a living will but who of the following would qualify as a consensus statement by the American College of Critical Care Medicine. Ethics Committee, American College of Critical Care Medicine, Society of Critical Care D. Recommendations for nonheartbeating organ donation: A position paper by the Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. The practice of euthanasia with the primary goal of hastening death Evidence-based guideline update: Determining brain death in adults Report of the Qual B. A provider withholding supportive treatment ity Standards Subcommittee of the American Academy of Neurology. A treatment, which will bene t a patient but may have undesirable side effects 74:1911-1918. Advantages: super cial anatomical location, relative distance from large veins and Nitric Oxide, Nitroglycerin, Sodium Nitroprusside nerves as well as considerable collateral circulation Acetaminophen overdose ii. Disadvantages: Relatively small arterial diameter means the catheter occupies a An injection of dyes such as methylene blue and indigo carmine produces spuriously signi cant portion of the intraluminal space, impeding the ow and increasing the risk low readings of arterial thrombosis (risk of thrombosis with 18g is increased relative to 20g catheter); An intense ambient light may interfere with pulse-ox. Cover pulse ox probe to a modi ed Allan’s test may be utilized to assess collateral circulation although its utility improve plethysmographic trace. If the arterial line transducer was accidentally lowered by 80cm, what pressure will be displayed on the monitor He remains intubated on cisatracurium, propofol, and based on individual patient assessment norepinephrine infusions. There are multiple invasive monitors in place including a pulmonary artery catheter and an arterial line. An arterial catheter is connected to rigid uid lled tubing of a monitoring system. The uid column in the tubing carries a mechanical signal created by the arterial pressure wave to the diaphragm of an electri cal pressure transducer that converts the mechanical signal into an electrical signal. The electrical signal is transmitted to the monitor and then is ampli ed and displayed. In order to assess the accuracy of the arterial pressure waveform, a fast ush test is used. A brief ush can be applied to the catheter tubing system to determine whether the recording system is distorting the pressure waveform or not. Most systems are equipped with a one-way valve that can be used to deliver a ush from a pressurized uid bag (usually at 300 mmHg). Release of the ush should result in a return to baseline after several oscillations. An optimally functioning system has one undershoot and a small overshoot before returning to baseline. An overdamped waveform may be due to the presence of bubbles, clot, lack of ush solution, lack of pressure in the ush system, or excessive bends in the system tubing. Underdamping is usually due to excessive tubing length (> 200 cm) or the use of excessively stiff tubing. As the pulse travels from the aorta to the periphery, the systolic pressure is ampli ed by re ected waves from the periphery. The initial upswing (dP/dT) of the arterial waveform is called the anacrotic limb and changes with cardiac contractility. It is steeper with the use of inotropes and shallower when decreased left ventricular afterload. Subsequent stroke volumes will decrease, re ecting the previously Clinical assessment for uid administration decreased venous return to the right ventricle. These smaller stroke volumes will result the need to assess the intravascular volume status of a patient is commonplace in the in a delayed (after the positive pressure breath is delivered) decrease in systolic blood intensive care unit and operating room. This is often prompted by clinical scenarios pressure and a smaller pulse pressure. For animated slides illustrating the intersection such as low urine output, low blood pressure, or high heart rate, suggesting that intra of the venous return and Starling curves, please refer to the supplemental material from venous uid therapy may be warranted. In addition to these clinical as the dynamic changes in the interaction between venous return and cardiac function that sessments, invasive monitoring of lling pressures has been traditionally used to guide occur with ventilation can be used clinically. The effects of the varying stroke volumes uid therapy in the intensive care unit and operating room. Since these phenomena are tied to changes in pleural after placement of a pulmonary artery catheter. These pressure measurements of cardiac pressure, they do occur in spontaneously ventilating patients as well, but their use in lling pressures have not been shown to be an effective tool for guiding uid therapy. This ques ical ventilation as compared to patients in whom the intersection of the venous return tion can be answered using the normal changes in stroke volume and cardiac output that and cardiac function curves occurs on the at portion of the Starling curve (and who are occur with positive pressure mechanical ventilation. Changes in pleural pressure affects the when all of the following conditions circulation by changing right and left ventricular loading and the pressure relationship are met. The initial decrease in venous arrhythmias or extra-systoles return is likely to due to transmission of the increased pleural pressure to intrathoracic • Mechanical ventilation with tidal structures causing an increased right atrial pressure (hindering venous return) and com volumes of 8 mL/kg pression of the intrathoracic vena cava. This decrease in venous return, via the Frank • Passive interaction between patient Starling relationship, results in a decrease in right-sided cardiac output that results in a and ventilator without triggered delayed (due to the pulmonary transit time of approximately 2 seconds) decrease in left breaths or dyssynchrony ventricular preload and cardiac output. The left ventricle is also affected by inspiration: the positive pleural pressure decreases the transmural pressure required to eject blood Figure 8. With positive pressure ventilation, an increase in the systolic pressure is 35 referred to as delta up and a decrease as delta down (which correlates best with preload siveness These values can be used to guide ogy 2005; 103:419-28 uid therapy, but consideration must be given to the clinical condition of the patient and the details of the clinical scenario, as differences in physiology may affect the interac tion between the ventilator and cardiac output in any particular patient. Jacobsohn E, Chorn R, O’Connor M: the role of the vasculature in regulating ve B. Afterload dependence nous return and cardiac output: historical and graphical approach. The patient is intubated and receiving • Point of care ultrasound has been shown therapy with norepinephrine and epinephrine infusions but continues to to make an impact on decision making and be hemodynamically unstable with a heart rate of 123, blood pressure of improve patient outcomes 83/58, and oxygen saturation of 92% on 100% oxygen. Central venous pressure is estimated at 16 and pulmonary pressures are estimated at • Lung ultrasound has had increased use 57/34 with a pulmonary artery occlusion pressure of 23. Its safety and portability allow for rapid noninvasive bedside assessment to aid in diagnosis and ongoing management of critically ill patients. In particular the etiology of hemodynamic instability can be dif cult to ascertain in pa tients with cardiac pathophysiology without the use of this diagnostic tool. Other ultrasound modalities useful in the intensive care unit are vascular ultrasound (for access and evaluation of thrombosis), abdominal ultra sound (for evaluation of free uid, aorta pathology), lung ultrasound (for evaluation of pleura, pneumothorax, interstitial edema, pleural effusion, and consolidations including pneumonia or atelectasis). The American College of Chest Physicians and Society of Critical Care Medicine have made recommendations on critical care ultrasound competencies. Also it has been shown in recent literature that ultrasound has a high impact on management decisions made in the intensive care unit. Lung ultrasound also has made great advances over the past 10 years and has3 become more useful in the evaluation of the acute hypoxic patient. As the clinician taking care of the patient and the operator of ultrasound image acquisition, the clinician has the advantage of making immediate decisions and impact on patient care. Chest Trauma with Hemodynamic Compromise the case presentation illustrates the dif culty that can be encountered when treating B. Intracardiac Thrombus is consistent with left ventricular failure but is also compatible with right heart failure, 4. Echocardiography can provide real time a) Thoracic Aorta images to distinguish between these etiologies. Absolute Examinations a) Esophageal Stricture b) Esophageal Mass c) Esophageal Diverticulum d) Mallory-Weiss Tear e) Dysphagia/Odynophagia Unevaluated f) Cervical Spine Instability 2. Failing Left Ventricle b) Hypovolemia a) Decreased Area Change c) Pulmonary Embolism b) Increased End-Diastolic Area d) Acute Valvular Dysfunction c) Increased End Systolic Area e) Cardiac Tamponade 2. Complications after Cardiothoracic Surgery a) Increased Right Ventricular Size a) Infective Endocarditis b) Intraventricular Septum bulges towards Left Ventricle b) Suspected Aortic Dissection or Rupture c) Pulmonary Embolus if echogenic density present 3. Identi cation of Pulmonary Edema (Interstitial syndrome) “B” lines with lung c) Aortic Regurgitation sliding found in anterior lung zones d) Aortic Stenosis 4. Identi cation of Deep Vein Thrombosis non-compressible vein b) Diastolic Collapse of Right Ventricle B. Vascular Access (central vein, artery, hemodialysis): Dynamic guidance is when the procedure is performed under direct guidance, with real time view of the needle. Based on this ultrasound, the pa Areas investigated include hepatorenal, splenorenal, pericardial space, and bladder tient was given diuretics and/or afterload reducing agents to treat the acute exacerba (posterior to bladder for uid). Assessment of Urinary Tract a)Hydronephrosis Lung b)Distended Bladder (ureteral jets) A. Pneumothorax Identi cation absence of lung sliding, and lung point which you can see part of the pleura sliding and the other part absent sliding, indicates pneumothorax and can estimate size based on location Tip sheets for all the above modalities can be found at: ccm. Effusion Identi cation, Characterization and Quanti cation quad and sinusoid tion/ultrasound/tip-sheets/ signs, anechoic space between diaphragm and lung. Guidance during Thoracentesis can use vascular probe to visualize rib space in obese patients, as well as best approach B. Identi cation of Consolidated Lung with or without Air Bronchograms can use to differentiate atelectasis from pneumonia “B” lines without lung sliding can indicate 39 Figure 9. Conclusion Ultrasonography provides the critical care physician with a tool to rapidly assess a pa tient’s condition. The most important quality of bedside/portable/point of care ultrasound is reproducibility. As the clini cian taking care of the patient, you can make interventions and immediately evaluate to see the results of your intervention. With technological advances image quality has improved allowing for the development of new applications for ultrasonography.

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