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Diagnosis: Cyanotic Congenital Heart Disease
I was paged to the neonatal nursery at * * * * * Hospital in order to assess, stabilize, and prepare this newborn male for transport to the Emergency Department at * * * * *.
Baby boy * * * * was born at about *** hours in the morning to a multiparus woman after an induced labour and via a vaginal delivery. The neonate was noted to have cyanosis shortly after delivery without signs of respiratory distress and the additional supplemental oxygen only marginally improved oxygen saturation. Capillary blood glucose was within normal limits, but an AP portable chest x-ray demonstrated a heart with a globular configuration and normal pulmonary vasculature. The possibility of cyanotic congenital heart disease as an underlying diagnosis was entertained.
A complete physical examination, as well as a review of all available laboratory investigations and x-rays, was performed by myself when I arrived in the neonatal nursery at * * * * * Hospital at *** hours. This revealed a term male newborn who was in no respiratory distress, but who had an oxygen saturation of about 75% on room air. There were no dysmorphic features, but the newborn was clearly cyanosed. The fontanelle was soft, the chest was clear to auscultation and no cardiac murmur was audible. There was also no gallop rhythm. There was no hepatosplenomegaly and femoral pulses were normal.
This newborn was connected up to a cardiac monitor and placed in an incubator. He was transferred via ambulance to the Emergency Department at * * * * * to undergo an urgent echocardiogram and cardiology consultation. He was suspected of having transposition of the great vessels.
Diagnoses: Coma; Generalized Seizure
I was paged to * * * * * General Hospital to assess, stabilize and prepare this ***-year-old girl for transport to the Intensive Care Unit at * * * * *.
This child presented to the Emergency Department at * * * * * General Hospital on the evening of ****, complaining of sudden onset of retro-orbital headache associated with nausea and vomiting. She subsequently collapsed and was taken to the Emergency Department where the child was found to be comatose on admission with deviation of the eyes to one side. However, the child was hemodynamically stable without a fever or rash and there were no signs of head injury or toxic ingestion.
Initial resuscitative interventions included sedation with intravenous midazolam and then endotracheal intubation and hyperventilation with 100% oxygen. A nasogastric tube was inserted to decompress the stomach and a Foley catheter was inserted into the bladder. The child was subsequently paralyzed with pancuronium and given an intravenous broad-spectrum antibiotic (ceftriaxone).
Initially, our plans were to retrieve the child at * * * * * General Hospital using helicopter as the mode of transport. However, poor visibility necessitated that we land in ***** and travel via ambulance towards ******and plans were made to have the child brought by ambulance and meet us part way along the highway.
Ambulance transfer occurred at approximately *** hours and the child was taken via ambulance back to ****** to meet the helicopter and to be transferred back to * * * * *. Assessment and resuscitation were continued in the ambulance en route to ******. A complete physical examination was undertaken by myself and no new physical signs were identified. In fact, the child's level of consciousness appeared to be improving once the paralytic agent and sedative had worn off. There appeared to be no cranial nerve deficits and gag reflex was present. The patient moved all limbs symmetrically when her level of consciousness increased.
The endotracheal tube was repositioned as it appeared that it had entered the right main stem bronchus and was secured there during the initial intubation. Further sedation was undertaken with intravenous midazolam and morphine.
The patient was ultimately transferred to the Intensive Care Unit at * * * * * for further observation and investigation.The most likely underlying diagnosis of this child's acute decrease in level of consciousness was a generalized seizure with a postictal phase.
Diagnosis: Closed Head Injury
I was paged to the Emergency Department at * * * * * Hospital in order to assess, stabilize and prepare this ***-year-old Caucasian boy for transport to the Emergency Department at * * * * * for neurosurgical consultation.
This patient was playing on a slide at a local playground and fell approximately 15 feet from the top of the structure onto the firm ground below. There was a possible loss of consciousness with a generalized seizure. The child was given assisted-bag-valve-mask ventilations for reduced respiratory effort by the ambulance crew and was transported to the local hospital.
At * * * * * Hospital, the child was noted to have fixed and dilated pupils and he was comatose with a Glasgow Coma Scale of 6. However, he was hemodynamically stable with spontaneous respiratory efforts.
The child underwent a series of x-rays to rule out cervical spine and skull fractures and he was observed there for several hours while awaiting arrival of the transport team.
There was progressive increase in level of consciousness, but the child had recurrent vomiting.
A complete physical examination as well as review of all available laboratory investigations and x-rays was performed by myself when I arrived in the Emergency Department at * * * * * Hospital at approximately *** hours.
The major features on examination were a decreased level of consciousness and injuries confined to the head. The Glasgow Coma Scale was depressed at 11, but the child was hemodynamically stable and oxygen saturation on room air was greater than 95%. Pupils were equal and reactive to light, but extraocular movements were roving. He had no signs of basal skull fracture, but there was an abrasion with an ecchymosis to the left forehead and a smaller abrasion over the chin. Scalp, skull and facial bones appear to be intact. Brainstem reflexes, such as corneals,and gag were intact. The cervical spine was normal to palpation. There was no signs of thoraco-abdominal, pelvic peritoneal or extremity trauma. The patient appeared to move all limbs symmetrically and perfusion to the extremities was normal.
This child was transferred via aircraft to * * * * * airport and then
via ambulance to the Emergency Department of * * * * *. He was seen
by the neurosurgeon on-call upon arrival and admitted for further observation
and possible computed tomography scanning of the head.
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