Acute chest syndrome: Difference between revisions
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==Background==
==Background==
===Causes===
#Occurs most commonly in the 2-4yr old age group and then declines with age
# most common pathogen- C.pneumonia then M.pneumonia and RSV
#Causes
# cause of acute chest were fat emb, infc and infarction
##Pulmonary infection
# xray findings of acute chest occur ~2.5d after admission
###C. pneumoniae and mycoplasma are most common organisms
# multilobar involvement, esp of lower lobes common
###May also be caused by viruses, H. flu, klebsiella, staph
##Fat emboli
###Lodge in pulmonary vasculature -> additional ischemia
##Rib infarction
##Overly aggressive IV hydration


==Work-Up==
==Work-Up==
# CBC
#CBC
# retic
#Retic count
# ABG
#VBG
# BC/sputum cx
#Bcx /sputum cx


==Diagnosis==
==Diagnosis==
Any chest symptoms with a new finding on CXR (however, CXR finding may be delayed)
#New infiltrate on CXR with at least one of the following:
# low grade fever
##Fever >38.5
# chest pain
##Cough
# cough
##Wheezing
 
##Tachypnea
DISCUSSION
##Chest pain
# sx at presentation are age dependent
#Note: CXR findings may lag behind the clinical features
##age less than 10 were wheeze, cough and fever.
##Age older than 20 is arm/ leg pain and dyspnea
# pain is prodrome
 


==Treatment==
==Treatment==
# Bonchodilators (even if no wheezing)
#O2
# Incentive spirometry
##Titrate to pulse oximetry
# Empiric ABX (for PNA)
#Hydration
# Pain management (to avoid splinting, hypoventilation, and narcosis)
##Oral hydration preferred
# O2 only if nec (maintian PaO2 <100)
##IV hydration with hypotonic fluid if pt unable to tolerate PO
# IVF for hypovolemia only
#Analgesia
# Consider transfusion (Leukocyte depleted blood products!) for
#Bronchodilators
##for heart dz
#Abx
##severe/worsening anemia
##Treat as if pt has community-acquired PNA
##multilobar PNA
#Tranfusion (leukocycte depleted)
##unresponsive hypoxemia
##Consider transfusion to goal of Hb 11 / Hct 30 for:
# Consider exchange transfusion for PaO2 <70 on high O2 + not improving
##O2 Sat <92% on room air
 
##Hct 10-20% below pt's usual Hct or dropping Hct
===Exchange Transfusion===
#Exchange transfusion
# Phlebotomize 500mL
##Consider for:
# NS 300mL bolus
###Progression of ACS despite simple transfusion
# Phlebotimize 500m:
###Severe hypoxemia
# Infuse 4-5 units PRBC
###Multi-lobar disease
 
###Previous history of severe ACS or cardiopulmonary disease
==Prognosis==
# Worsens with age
# Resp failure predictors:
##bad xray, thrombocytopenia (<200), h/o cardiac dz
 
===Concerning Workup===
# Dec Hb
# inc WBC x 2
# platelet <200


===Complications===
===Complications===
#[[PE]] (bone marrow, fat or thrombotic)
#[[Pulmonary Embolism]] (bone marrow, fat or thrombotic)
#[[Pneumonia]]
#[[Pneumonia]]
# pulm hem
#[[CVA]]
#cor pulm
#hypovolemic shock from splenic seq
#[[Sepsis]]
#[[Sepsis]]
#Intracranial hem
#[[Seizure]]
#Neuro events = [[AMS]], neuromusc events, [[seizure]], anoxia
## strong relation between acute chest and neuro complications
## RF = low platelets


==See Also==
==See Also==
Heme: Sickle Cell Crisis
[[Sickle Cell Crisis]]


==Source ==
==Source ==
8/07 DONALDSON (adapted from Mistry)
*Tintinalli
*UpToDate


[[Category:Cards]]
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Revision as of 22:56, 20 October 2011

Background

  1. Occurs most commonly in the 2-4yr old age group and then declines with age
  2. Causes
    1. Pulmonary infection
      1. C. pneumoniae and mycoplasma are most common organisms
      2. May also be caused by viruses, H. flu, klebsiella, staph
    2. Fat emboli
      1. Lodge in pulmonary vasculature -> additional ischemia
    3. Rib infarction
    4. Overly aggressive IV hydration

Work-Up

  1. CBC
  2. Retic count
  3. VBG
  4. Bcx /sputum cx

Diagnosis

  1. New infiltrate on CXR with at least one of the following:
    1. Fever >38.5
    2. Cough
    3. Wheezing
    4. Tachypnea
    5. Chest pain
  2. Note: CXR findings may lag behind the clinical features

Treatment

  1. O2
    1. Titrate to pulse oximetry
  2. Hydration
    1. Oral hydration preferred
    2. IV hydration with hypotonic fluid if pt unable to tolerate PO
  3. Analgesia
  4. Bronchodilators
  5. Abx
    1. Treat as if pt has community-acquired PNA
  6. Tranfusion (leukocycte depleted)
    1. Consider transfusion to goal of Hb 11 / Hct 30 for:
    2. O2 Sat <92% on room air
    3. Hct 10-20% below pt's usual Hct or dropping Hct
  7. Exchange transfusion
    1. Consider for:
      1. Progression of ACS despite simple transfusion
      2. Severe hypoxemia
      3. Multi-lobar disease
      4. Previous history of severe ACS or cardiopulmonary disease

Complications

  1. Pulmonary Embolism (bone marrow, fat or thrombotic)
  2. Pneumonia
  3. CVA
  4. Sepsis

See Also

Sickle Cell Crisis

Source

  • Tintinalli
  • UpToDate
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