You are presented with a 7 year old male child with acute painful swelling in the left scrotum, vomiting and torsion of the testes. He has had a cough and been wheezing for 3 days. He had his last meal 4 hours ago. He has been asthmatic for the past 3 years and is currently taking salbutamol and beclomethasone inhalers.
The child is found to be very anxious and in pain. He is mildly dehydrated, and weighs 19 kg.
– Respiratory rate: 28/min
– Left lower zone: air entry decreased
– Percussion note decreased
– Bilateral rhonchi
– Abdominal examination: scrotum – nothing abnormal detected
– Heart rate: >120 bpm
– Blood pressure: 110/60 mmHg
– Auscultation: nothing abnormal detected
The result of investigations are as follows:
– Haemoglobin: 10.6 g/dl
– White blood cell count: 14,600/ml
– Neutrophil count: 80 x 106 ml (Normal range 2-7)
– lymphocyte count: 20 x 106 ml (Normal range 1.5-4)
– Packed cell volume: 40%
Other investigations carried out:
– Chest X-Ray
– Urea and electrolytes
QUESTIONS (answers below)
1. Summarise the patient and identify the problems associated with this case.
2 Give the differential diagnosis.
3. Discuss childhood asthma.
4. How do you assess severity of asthma?
5. Comment on investigations.
6. How would you manage this child?
7. How would you anaesthetise this child?
1. Emergency surgery - risk of ischaemia
Lower respiratory tract infection
2. Infection - epididymo-orchitis, abscess
Trauma – haematoma
3. Disappears after about 10–15 years
10–15% progress to have adult asthma
Family history of atopy
4. Patient’s history:
Off school/work - frequency
Hospital admissions/ITU admissions
Steroid courses given
Heart rate: pulsus paradox
Cyanosis - very late
PEFR <30% predicted
5. White blood cell count increase: could be due to epididymo-orchitis or urinary tract infection
Haemoglobin decrease: could be due to malnutrition
Is the child dehydrated?
Weight: expected weight 22 kg [(age x 2) + 8 kg]. Why has his weight decreased?
6. The following areas should be covered:
Fluids - maintenance and allowance for dehydration, signs of adequate hydration
Treat infection; steroid cover
EMLA/AMHOP (Eutectic mixture of LA)
Rapid sequence induction: as the child has a full stomach, suxamethonium? rocuronium
Endotracheal tube size: diameter - [Age/4] + 4.5 ; length - [Age/2] + 12
Non-steroidal anti-inflammatory drugs
Caudal anaesthesia - dose