Pediatric Examination and Board Review (21 page)

• no eye movement in response to turning the head (doll’s eyes, oculocephalic reflex)

• no response to cold water into the ear canal (oculovestibular reflex testing)

• no movement of bulbar muscles (tested by checking for the presence of the corneal reflex, the gag reflex, coughing, suckling, or rooting)

• patient is apneic off mechanical ventilation (this assumes the patient does not have a cervical spine injury that would prevent breathing efforts even in the face of a normal functioning brainstem)

• Apnea testing needs to be performed in a fashion that guarantees the patient neither becomes hypoxemic nor hypotensive during the period of challenge. There must also be demonstration of respiratory acidosis to a pH that is 7.25 or less with concomitant absence of respiratory efforts in order to declare that the patient in fact has no respiratory brainstem function.

3. absence of hypotension or hypothermia during the examination

4. muscle tone should be flaccid and there should be no spontaneous movements and no response to central painful stimuli

5. confirmatory testing requirements are defined again by age, and no confirmatory test is required or recommended for children older than 1 year of age without other injury

The presence of deep tendon reflexes (DTR) does not preclude the diagnosis of brain death even though it is more common for them to be absent. DTRs are considered spinal reflexes, as is flexion of an extremity in response to painful stimuli applied to the distal part of that extremity. Those movements, with time, almost always vanish and do not negate the determination of brain death but can be confusing to families.

An examination for brain death by a neurologist or neurosurgeon is not required by the current societies of neurology or pediatrics, although it is recommended that a physician who is familiar with this examination be asked to evaluate the patient. This physician might be a neurologist, neurosurgeon, intensivist, neonatologist, or emergency department physician. Clearly there are local requirements, both in individual academic practices or private hospitals, that define the requirements for the declaration of brain death in each venue.

12.
(B)
The notion of brain death was first described by Dr. Henry K. Beecher, a neurologist from the Harvard Medical School in 1968. This concept was introduced in an effort to identify patients with irreversible coma who could be considered for an organ transplant. These criteria for irreversible coma later became the criteria for brain death determination. However, these guidelines omitted children. It was not until the mid-1980s that the issues of hypoxicischemic encephalopathy progressive to brain death and the definition of brain death in children were addressed. The diagnosis of brain death in children as currently described by the leading societies of neurology and pediatrics has specific recommendations for performing a brain death examination as well as the use of confirmatory data.

13.
(B)
Modern definitions of brain death in adults and children older than 1 year of age require only that the examination of the patient be consistent with brain death and that there not be confounding issues that will prevent the accuracy of that examination (as with a cervical spine injury). Multiple examinations are recommended in children younger than 1 year of age. The American Academy of Pediatrics as well as the American Society of Neurology and Neurosurgery suggest that confirmatory tests of brain function be used in these young children. For infants 7 days to 2 months of age, they recommend 2 physical examinations and 2 EEGs separated by 48 hours. Between 2 months and 1 year, 2 physical examinations and 2 EEGs separated by 24 hours are recommended. Beyond 1 year of age, physical examination alone is sufficient. It is suggested, but not required, that an observation period of at least 12 hours be used in the older child in whom 2 examinations are performed. A nuclear medicine study of cerebral blood flow or a cerebral angiogram can replace the 2 EEGs in either case.

14.
(C)
See answers to questions 11 and 13.

15.
(B)
If there is an additional injury, particularly a cervical spine injury, which interferes with the apnea test, the brain death examination is not valid. Even with intact cerebral and/or brainstem function, apnea would be present in the child with the cervical spine injury above or involving C3. Diaphragmatic paralysis and thoracic weakness are found with injury to C4 and C5, also confounding the apnea test. Therefore, one cannot do a brain death examination accurately in the presence of cervical spine trauma. A test such as a cerebral angiogram or nuclear medicine study is needed to confirm the absence of cerebral blood flow. Hypothermia, an excessive dose of barbiturates, or other metabolic intoxications also limit the accuracy of the brain death examination. Before testing, it is required that patients be normothermic with a barbiturate level sufficiently low so as not to confound the examination.

S
UGGESTED
R
EADING

Ashwal S, Schneider S. Brain death in children: part I.
Pediatr Neurol.
1987;3:5-11.

Lavelle JM, Shaw KN. Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?
Crit Care Med.
1993;21(3):368-373.

Liller KD, Kent EB, Arcari C, et al. Risk factors for drowning and near-drowning among children in Hillsborough County, Florida.
Public Health Rep.
1993;108(3):346-353.

Meyer RJ, Theodorou AA, Berg RA. Childhood drowning.
Pediatr Rev.
2006;27(5):163-168.

Quan L, Gore EJ, Wentz K, et al. Ten-year study of pediatric drownings and near-drownings in King County, Washington: lessons in injury prevention.
Pediatrics.
1989;83(6):1035-1040.

Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome.
Pediatrics.
1992;90(6):909-913.

Wintemute GJ, Drake C, Wright M. Immersion events in residential swimming pools. Evidence for an experience effect.
Am J Dis Child.
1999;145:1200-1203.

CASE 10: A 2-YEAR-OLD BOY WITH SUDDEN ONSET OF COUGHING

A 2-year-old boy is brought to the emergency department with the sudden onset of coughing. He has not had any symptoms of upper respiratory tract illness. He has no past history of reactive airway disease, nor a family history of asthma. Before the onset of symptoms, he was playing with his older sister in the kitchen.

On physical examination the child is nontoxic but cannot stop coughing. Results of his physical examination are normal except his room air saturation is 94% and auscultation of the chest reveals wheezing in the right hemithorax and coarse breath sounds throughout.

SELECT THE ONE BEST ANSWER

1.
Which of the following would be the best way to order radiographs to maximize potential for identifying the presence of a radiolucent foreign body in a cooperative child?

(A) AP and lateral chest films

(B) posteroanterior (PA) and left decubitus chest films

(C) inspiratory and expiratory films

(D) right lateral decubitus film

(E) a single view of the chest

2.
If the child cannot cooperate with the requested chest X-ray (CXR), what is the next most appropriate diagnostic test?

(A) a chest CT scan

(B) a chest MRI

(C) an airway fluoroscopy

(D) a ventilation/perfusion study

(E) rigid bronchoscopy

3.
This child has a normal CXR. Which of the following statements is true?

(A) a normal CXR rules out a foreign body in the airway

(B) many children with a normal CXR have had airway foreign bodies

(C) a normal CXR mandates that you proceed to a CT for diagnosis if a foreign body is suspected

(D) the CXR must be mislabeled because this child could not have a normal CXR

(E) none of the above

4.
The most common aspirated airway foreign body in childhood is

(A) a peanut

(B) a marble

(C) a hot dog

(D) a balloon

(E) a coin

5.
The most common airway foreign body that is lethal is

(A) a peanut

(B) a marble

(C) a penny

(D) a balloon

(E) a hot dog

6.
The most common esophageal foreign body found in children is a

(A) matchstick

(B) marble

(C) penny

(D) quarter

(E) peanut

7.
The most appropriate therapeutic intervention when there is a suspected tracheal foreign body in a coughing child would be

(A) urgent thoracotomy

(B) urgent upper GI

(C) urgent bronchoscopy

(D) the Heimlich maneuver

(E) emergent tracheostomy

8.
If the radiograph reveals a coin in the proximal esophagus, what would the appropriate intervention be?

(A) send the child home; the coin will pass without intervention

(B) remove the coin in the emergency department using a balloon-tipped catheter