Indian Journal of Trauma and Emergency Pediatrics

Neonatal seizures are usually an acute manifestation of disturbance of the developing brain and are very common in the first weeks of life (1-5 per 1000 live births). The outcome of neonates with neonatal seizures has changed in recent years due to improved prenatal care, better obstetrical care and intensive neonatal care. However, it still remains an important contributor to future neurological complications. Based on this, immediate and aggressive anticonvulsant therapy seems reasonable, but standardized approaches to the treatment of neonatal seizures remain undeveloped. There is a paucity of strong clinical evidence on the efficiency of anticonvulsants and their effects on neurodevelopment. In particular, few studies address the issues related to the use of antiepileptic drugs (AEDs), as first-line and second-line agents. Nevertheless, despite concern about diagnosis, most physicians choose to treat neonates who have seizures, most commonly with either phenobarbital or phenytoin as first line drug. In the current clinical query we have tried to address the unresolved issue of first line drug treatment for neonatal seizures, which would benefit the clinician in taking an evidence based decision for the treatment of neonatal seizures. Development of a safe and effective treatment strategy for neonates with seizures remains an important priority for future research.

Key words: Seizures; Neonate; Phenytoin; Phenobarbitone.

Although digoxin has played a major role in the therapy of congestive heart failure, its narrow therapeutic index, limited published data on efficacy in children, and the widespread availability of newer drugs like Angiotensin Converting Enzyme inhibitors, has made clinicians questioning the role of digoxin in the present day management of heart failure in children. In this article we have tried to focus on the literature available on the use of these two agents either alone or in combination with other agents and have tried to come up with practical recommendations that are specific to a particular physiologic state.

Key words: Cardiac failure; Cardiac glycosides; Digoxin; ACE inhibitor. 

Pneumothorax, pneumomediastinum and subcutaneous emphysema due to foreign body aspiration (FBA) are rarely encountered in clinical practice. Epidural emphysema or pneumorachis as it is known is an even rarer condition associated with FBA reported infrequently in literature. We present here, a rare case of FBA encompassing features of all of the above mentioned entities in a preschooler who presented with symptoms of acute respiratory distress following a respiratory tract infection of 2 weeks duration. A possibility of foreign body aspiration was considered on the basis of her clinical and radiological investigations suggesting hyperinflation and collapse at different places with air leaks leading to the above complications. Accordingly, a diagnostic bronchoscopy was performed which revealed a peanut in the left main bronchus which was successfully extracted leading to resolution of symptoms in the child.

Key words: Foreign body aspiration; Pneumothorax; Pneumomediastinum; Pneumorachis; Epidural emphysema; Bronchoscopy.

Methemoglobinemia is a condition in which the iron within the hemoglobin is oxidized from the ferrous (Fe2+) state to the ferric (Fe3+) state, resulting in an inability to transport oxygen to the tissues. Acquired methemoglobinemia, more common than the congenital forms, has been reported following exposure to a number of medications and oxidizing substances. Presentation may vary from cyanosis to frank seizures, coma and death depending on the levels of methemoglobin (MetHb) in blood. MetHb levels more than 70% have almost always reported to have been fatal. However, the level of MetHb may not always correlate with severity of illness or predict outcomes in these cases as was seen in the two cases reported here. While a 6 year old boy with thinner ingestion and MetHb levels of 85% survived, an adolescent girl with levels of 28.5% succumbed to her injuries. Both the children presented with severe respiratory distress and cyanosis that persisted despite 100% oxygen and positive pressure mechanical ventilation. Methemoglobinemia was suspected in both cases due to the presence of ‘oxygen saturation gap’ and confirmed by estimating the blood MetHb levels. Despite an alarmingly high MetHb level the boy survived probably due to early presentation and aggressive goal directed resuscitation. On the other hand, the girl with levels of only 28.5% succumbed to her injuries probably due to delayed presentation and prolonged cerebral anoxia prior to presentation.

Key words: Methemoglobinemia; Methylene blue; Oxygen saturation gap.

Background: Few studies have evaluated the demographic characteristics, clinical profile and outcome of children with snake envenomation prospectively.Objectives: To evaluate the clinical profile and outcomes of critically ill children with snake envenomation. Methods: This prospective observational study was conducted over a 2 year period from November 2007 to January 2010 in a Pediatric intensive care unit of a tertiary care teaching hospital. Children less than or equal to 12 years of age admitted to our hospital with a definitive history of snake bite were enrolled in the study. Children were treated as per the World Health Organization guidelines on the management of snake bite in children (2005).Results: Out of 67 children studied, 70% (n=47) were males. The presenting features were hemotoxic in 42 (62.7%), neurotoxic in 12 (18%), and only local symptoms in 13 (19.4%) children; bleeding from the site of bite and mucosa was the commonest manifestation. Use of pre-hospital first aid measures such as tourniquet and/or native treatment was found in 25% and 12% of the children respectively. While all children with hemotoxic and neurotoxic features received anti-snake venom, only nine with exclusive local symptoms required it. Ventilation, inotropes, blood products and dialysis were required in 14 (21%), 7 (10%), 11 (16%) and 11 (16%) patients respectively. Of the 67 children, 10(15%) died and 3 (4.5%) had major disability in the form of necrosis and/or skin graft. The commonest causes of death were acute kidney injury and disseminated intravascular coagulation (4 and 3 respectively). Conclusion: Majority of children had features of hematotoxic envenomation. One fifth of the study population had poor outcomes in the form of death and/or major disability.

Key words: Snake envenomation; Snake antivenom; Hematotoxic; Neurotoxic; Snake bite; Whole blood clotting time. 

 Not Provided.