PRESENTATION

• Name ,age - Sanvi k, 1 year 7 month old female

• Residence - Krishnagiri
• Date of admission – 29/5/22 @4.20pm
• Date of discharge – 4/6/22 (DAMA)

• Final Diagnosis –
foreign body aspiration (areca nut)
s/p bronchoscopy – removal
Hypoxic seizure
Anemia not in failure
Presenting complaints
Cough x 15 days
Fast breathing x 10days
Up rolling of eyes/stiffening of b/l Upper limb and lower limb x 3
episode
Urinary retention x 1 week
History of presenting complaints
Cough and cough X since 15 days
• Wet sounding
• Mainly during night, no postural variation

 fast breathing noticed on the 3rd day

Abnormal movements X 3 episode

• stiffening of b/l upper limb and lower limb lasting for 10 minutes.
• Up rolling of eyes
• bluish discolouration +
• No frothing, urinary or bowel incontinence
 Anekkal hospital
22/5/22
23/5/22 29/5/22
1st episode 2nd episode 3rdepisode
11pm 2pm 5am
lasting for 10min lasting for 10sec lasting for 1minute
Anekkal hospital ICU ICU
Ward Intubated for 1 day CPR, Bag and mask
(8 hours)
Negative history
• No h/o fever
• No h/o rashes
• No h/o vomiting
• No h/o breathlessness
• No h/o cyanosis, palpitation, chest pain
• No h/o jaundice
• No h/o bleeding manifestation
• No h/o dysuria
COURSE BEFORE COMING TO SJMCH
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Gunam 1st Episode 2nd Episode 5am

Cough
hospital Uprolling of eyes Intubated for 3rd episode
Fast Stiffening of 1 day(8hrs)
Anekkal
breathing b/l UL &LL
10min

ICU ward ICU ward ICU SJMCH

CXR - L BP haziness UTI-enterococcus hypokalemia(K- 2) ECHO – normal

fecalis USG abdomen-
Urine R/M – normal USG abdomen- b/l pyelonephritis
Mild ascites, multiple
abnormal intrasluminal
echo in bladder
BIRTH HISTORY
DOB- 26/10/2022
Antenatal/intrapartum – uneventful
19 YEAR 17 YEAR 3M 1Y 7M

Type of Delivery – Normal vaginal delivery

Birth weight – 2.5kg
No Neonatal asphyxia/jaundice/seizure

IMMUNIZATION HISTORY –
Till 9 months

PAST HISTORY –
At 3 months of age- cold and cough x 2 days, received nebulization
At 6 months of age – cold, cough, fever x 2days, nebulization for 3 days

FAMILY HISTORY –
No h/o seizure in the family

DIETARY HISTORY – bottle feeding present

General examination Anthropometry

• Child was active and alert • Weight – 11.5kg (0,+2)

• Pallor present, • Height – 87cm (0,2)
• T- Afebrile • Weight/height – (0,-1)
• HR-140 /min • HC – 48cm(0,1)
• RR-32/min • MAC – 16cm
• SPO2 :96% on room air
100% oxygen@ 5L/mt
• BP- 88/60 mm of Hg
Developmental history

Gross motor Fine motor Language Social

Head control-3m Scribbles- 1 ½ year monosyllable – 6m Social smile – 2m
Stand with support – Bisyllable – 8m
6m 3-4 meaningful
Stand – 1 year words – 14 m
Walk – 1 ½ year
Systemic examination
Respiratory System -
Resonant all over lung field,
stridor +
crepitations all over lung
Prolonged expiration
Abdomen
Distended. No shifting dullness
Liver 4cm below RCM, span 10cm, soft, normal border, nontender
Spleen not palpable
Provisional diagnosis
Foreign body
WALRI
Severe community acquired pneumonia
Anemia not in failure
Faulty feeding
Initial Impression —> Life threatening IN ER (at 4.20pm )
Primary assessment

A- IRRITABLE
B- INCREASED WORK OF BREATHING
C- PALE

A- Maintainable
B- RR- 30/min, Spo2- 96% in RA, ICR/SCR, Added sounds present
C- HR-132bpm, BP- 111/60, PP- wellfelt, Peripheries – warm, CFT- <3
sec, Urine output- Normal
D- GCS-15, E4 M6 V5, Pupils 2mm, equal and reactive, No
seizures/posturing
E- Temp- 98.6F

Primary Impression —> Respiratory distress- lower airway, O2

General examination
• Pallor ++
Systemic examination
• RS- Bilateral air entry equal, extensive crepitations with extensive wheeze
• CVS- S1 S2 normal
• PA- soft, no tenderness, liver 4cm RCM, spleen not palpable
• CNS-. GCS-15/15, Tone – normal, reflex- normal

WORKING DIAGNOSIS-
1. Bronchopneumonia with anemia(not in failure, ? nutritional) and
hepatomegaly
2. Bronchopneumonia to r/o foreign body aspiration with ?apnoeic spell /
seizures
ABG
• pH- 7.36
• pO2- 44.1mmHg
• NA+/K+/Cl- 144/3.9/113
• Ca2+ - 4.66
• Lac – 9
• HCO3 – 24.2
• Anion gap – 6.2
• CO2- 57.2
• pO2- 84.4
29/5/22 4.57pm
Treatment given in ER
• Neb. 3%NaCl 3ml
• O2 @5L/min via face mask
• Inj. Ceftriaxone 580 mg iv
• IVF ½ DNS @45ml/hr +1cc KCl/100ml IVF

• Child is a shifted to PITU at 6pm

Preliminary Lab report investigations
• Hb- 6.60 • Sodium- 145meq/dl
• PCV- 28.8% • Pottasium- 2.53 meq/dl
• TC- 13,930 DC-( N/L/E/M) • Chloride - 99
48/46/1.3/19.5 • Creatinine- 0.38
• Nucleated RBC- 354
• PC- 2.22 lakh
• Retic count-0.92
• MCV – 55.9
• MCH- 12.8
• MCHC – 22.9
DATE HB/PCV TC PLATELET TB/DB SE Creat/
Calcium

18/5/22 7.4/24.6 6200 5.11 73/23

7.31/6.65 12430 6.65 44/49 136/4.29/107 0.4

19/5/22
9.2
22/5/22 3.08 0.34

25/5/22 2.71

27/5/22 3
29/5/22 6.60/28.8 13.93 2.22 48/46 145/2.53/99
SJMCH 3.47

143/3.20/98
29/5/22 (6pm ) Inj. Lorazepam
On examination - Inj. Hydrocortisone
drowsy IVF ½ DNS
HR-141bpm Neb. 3%NaCl
BP – 122/82 mm of Hg Neb. Salbutamol
RR- 27/min Neb. Ipravent
Chest examination – O2 @5L/min via Face mask
• stridor present, 1unit PRBC
• expiratory wheeze, Inj. KCl 3cc 30ml over 1 hour under cardiac
• b/l wheeze supraclavicular and monitering
suprasternal retractions
Hb- 6.60
Pottasium- 2.53 meq/dl
TREATMENT RECEIVED
Inj. Ceftriaxone
30/5/2022 (8am) TREATMENT RECEIVED
HR-142 /min Inj. Ceftriaxone
RR – 32/min Inj. Hydrocortisone
BP - 126/81 mm of Hg Inj. Fosphenytoin
SpO2- 97% in RA, Inj. KCl
RDS-4/10 IVF ½ DNS
RS- ICR +, crepitations +,stridor+ O2 @5L/min via face mask
prolonged expiration Neb. Ipravent
Issues Saline nebulization Q6hrly
1 Respiratory distress
2. Nutrition – IVF full maintenance
3. Hypolakemia
4. Seziure
30/5/2022 (10 am )
HR- 160/min
RR- 30/min
BP- 100/60
SpO2 – 98%
B/L conducted sound, sternal and suprasternal retractions.
Plan :
To plan for Bronchoscopy with PESU
Stop salbutamol and Ipratropium

Child is shifted to PICU i/v/o respiratory distress.

IN PICU
DAY 1(30/5/22)
Irritable with increased respiratory distress HFNC , flow 20L/min,
FiO2- 40%
Provisional Diagnosis made in PICU in the initial stage – WALRI with
bronchopneumonia
Rx – Ceftriaxone, Azithromycin, Oseltamivir, Fosphenytoin, stat dose of
MgSO4 with hydrocortisone
Chest X ray- b/l increased bronchovascular markings.
Paediatric surgery – posted for bronchoscopy on 31/5/22
31/5/77 1.13pm
 DAY 2 in PICU 31/5/22

• Anaesthesia team advised for intubation

11
am

• 1 episode of hypoxic seizure GTCS lasting for 15 sec – loaded with leviteracetam,
11. midazolam.
30a • I/v/o desaturation – intubated and connected to mechanical ventilation
m
• – As child was being shifted to OT on portable ventilator child was noticed to have
tachycardia, HR-149/min, SpO2 – 40%.
I/v/o bradycardia with desaturation , reassessed the child HR-50/min, inadequate chest
12.00 pm rise,
• CPR done 1 dose of adrenaline given, HR 100/min, SpO2 85%.
• Child was reintubated with 5 cuffed tube SpO2 – 75%continued on bag ventilation,
• Chest Xray s/o Collapse

2.0 • shifted to OT
0
pm
Bronchoscopy
Anaesthesia given at 3.30 end time 4.10
Operative procedure- bronchoscopy with foreign body retrieval
Foreign body (a piece of areca nut ) impacted in the right primary
bronchus removed in toto, mucosa inflamed, secretions +
Post Op events - Mechanical ventilation continued for 48 hours,
i/v/o hypotensive episode – fluid resuscitation , low dose ionotrope
adrenaline for 24hrs continued.
Piperacillin tazobactum is added, oseltamivir stopped. Dexa continued
for 72hrs
31/5/22 5.38pm 1/7/22 5.50am
3/5/22 5.57am
Day 5 (3/6/22) child was extubated to HFNC. NG feeds started.

Day 6 (4/6/22 )Due to financial constraints child went DAMA

DISCHARGE ADVICE
Inj. Pipercacillin tazobactum 1.2gm iv Q8hrly
Syp.Levetiracetam 1.2ml -0-1.2ml
Tab. Lanzoprazole 10mg OD
To continue HFNC for further 24 hrs