Pediatric emergency medicine trisk 2796 2796

pharynx, or upper airway Findings may be mild with blood-streaked sputum, or patients may present with massive blood loss and shock Hypoxia and shortness of breath are most likely with significant hemorrhage or as a result of exacerbation of underlying condition Apprehension is not uncommon in these children as dyspnea is compounded by the visualization of blood loss Children with recurrent intrapulmonary bleeding are more likely to be anemic As a result, they may also present with fatigue and poor weight gain as symptoms Examination findings are often nonspecific and include tachypnea, tachycardia, and hypoxia Crackles may be appreciated over the affected area, although isolating the location of the bleeding by auscultation is difficult For older patients, identifying the affected area may be best accomplished by asking the patient where they feel pain or discomfort Other signs on examination may be helpful in elucidating an underlying diagnosis, such as abnormal cardiac sounds with heart failure, rash or joint involvement with collagen vascular disease, or external signs of thoracic injury in trauma patients Cardiorespiratory decompensation can occur in children with severe anemia or shock from severe hemorrhage Radiographs will vary depending on etiology Alveolar infiltrates may be transient localized processes, or diffuse and chronic In idiopathic pulmonary hemosiderosis, diffuse alveolar changes are usually symmetric and spare the apices and costophrenic angles (See Fig 99.4 ) Because most children swallow their sputum, a presumptive diagnosis can be made by finding hemosiderin-laden macrophages in nasogastric washings; these macrophages will stain blue with Prussian blue reaction More definitive diagnosis, however, requires bronchoscopy and bronchoalveolar lavage (BAL) Finding similar macrophages from BAL is diagnostic, and direct visualization of the airways provides an opportunity to potentially localize the site and assess the activity of bleeding Lung biopsy is required only for patients with recurrent bleeding in whom no diagnosis can be made on a clinical basis and alternative systemic diseases cannot be excluded