RESUMEN

One feature of autism spectrum disorder (ASD) is a deficit in verbal reference production, that is, providing an appropriate amount of verbal information for the listener to refer to things, people, and events. However, very few studies have manipulated whether individuals with ASD can take a speaker's perspective to interpret verbal reference. A critical limitation of all interpretation studies is that comprehension of another's verbal reference required the participant to represent only the other's visual perspective. Yet, many everyday interpretations of verbal reference require knowledge of social perspective (i.e., a consideration of which experiences one has shared with which interlocutor). We investigated whether 22 5;0-7;11-year-old children with ASD and 22 well-matched typically developing (TD) children used social perspective to comprehend (Study 1) and produce (Study 2) verbal reference. Social perspective-taking was manipulated by having children collaboratively complete activities with one of two interlocutors such that for a given activity, one interlocutor was Knowledgeable and one was Naïve. Study 1 found no between-group differences for the interpretation of ambiguous references based on social perspective. In Study 2, when producing referring terms, the ASD group made modifications based on listener needs, but this effect was significantly stronger in the TD group. Overall, the findings suggest that high-functioning children with ASD know with which interlocutor they have previously shared a given experience and can take this information into account to steer verbal reference. Nonetheless, they show clear performance limitations in this regard relative to well-matched controls. Autism Res 2018, 11: 1366-1375. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: No one had studied if young children with autism spectrum disorder (ASD) could take into account previous collaboration with particular conversation partners to drive how well they communicate with others. In both their language understanding and spoken language, we found that five to 7-year-olds with ASD were able to consider what they had previously shared with the conversation partner. However, they were impaired when compared to typically developing children in the degree to which they tailored their spoken language for a specific listener.

Asunto(s)

RESUMEN

Approximately 4% of children experience febrile seizures, making it one of the most common childhood neurologic disorders. Most incidences occur between six months and three years of age, and 30%-40% of these children will experience a recurrence. The priorities in emergent management of pediatric seizures are airway maintenance, seizure termination and correction of reversible causes. When a child experiences a febrile seizure, gradual passive cooling will assist the child in terminating it. The exact cause of febrile seizures is still uncertain, but studies seem to suggest that the height of the fever is less of a factor than the rapidity of its rise. In other words, a child is more likely to seize if his or her temperature rises rapidly, even if it reaches a lower maximum temperature. The same child may slowly increase his/her temperature to a higher maximum without suffering a seizure. In this case, the patient obviously had a respiratory infection that was the source of the fever. It is important to reassure the parents in such a case of the benign nature of febrile seizures and that less than 5% of children experiencing them will develop a seizure disorder. The seizure in this case was terminated with i.v. Atvan, a drug that has been shown to work well as an anticonvulsant in children. But in most circumstances, a febrile seizure will end spontaneously or with gentle cooling. Either acetaminophen or ibuprofen can be given to treat the fever, and rectal forms of these medicines are preferred in the early treatment phase. Oral forms of the medicine can be administered after the child has stopped seizing and is not vomiting. The child should be exposed to a cooler, but not cold, environment, and the airway supported. Tepid baths can help to bring down a fever, but alcohol rubdowns or any fast cooling measures should be avoided because they may induce shivering and further elevate the fever.

Asunto(s)

RESUMEN

The lungs are surrounded by the pleural membranes. The visceral pleura directly covers the lung and is separated from the parietal pleura by a layer of surfactant, which reduces friction during respiratory movement. A potential space exists between these two layers, and they may become separated by fluid or air. A lung can collapse to the size of a fist under pressure from either. Standard treatment in the field for an open chest wound is an occlusive dressing. The first thing that can be used to occlude the wound is a gloved hand. After placing the dressing, evaluate the breath sounds and determine if they have improved. The dressing should be taped down on three sides, leaving one side open to relieve the pressure during exhalation (one-way valve). "Burping" the dressing involves lifting one side to make sure any pressure buildup is relieved, as occasionally the dressing can become adhered to the skin, which may lead to a tension pneumothorax. If, after ensuring the occlusive dressing is properly in place, the respiratory rate increases, distress level worsens, oxygen saturations fall and breath sounds decrease, then needle decompression is required. A neurovascular bundle is located underneath each rib, and it is important to avoid damage to that bundle by performing a decompression over the top of a rib. If the patient is intubated before the development of a tension pneumothorax, carefully evaluate the breath sounds (especially if the left-side sounds are diminished) to determine if the ET tube needs to be withdrawn a centimeter. The rescuer performing ventilation will usually recognize a tension pneumothorax by the difficulty in bagging the patient. Remember, when you perform a needle thoracentesis, you are creating an open chest wound. Early signs and symptoms of a tension pneumothorax include diminished or absent breath sounds, severe dyspnea, narrowing pulse pressure, tachycardia and restlessness. Neck veins may be distended, but this can be a normal finding in a supine patient. The classic sign is a deviated trachea; the trachea shifts toward the "good" lung as the buildup of pressure collapses the "bad" lung. This is a late sign and suggests the tension pneumothorax has been developing for some time. One sign that does not normally accompany a plain pneumothorax is hypotension. In this case, the persistent low BP, combined with cool, mottled skin and a delayed capillary refill time, led providers to suspect that a hemothorax was developing as well. With endotracheal intubation and pleural decompression, the positive-pressure ventilations allowed the affected right lung to inflate more fully, utilize more of the available alveolar space and "bag out" some of the blood pooling at the base. The patient's vital signs and saturation improved. He needed surgical treatment and removal of the blood in the pleural space before ventilation and oxygenation could normalize.

Asunto(s)

RESUMEN

An aneurysm is an abnormal dilatation of an artery, often as a result of atherosclerotic disease. Hypertension, connective-tissue disease and a family history of aneurysms are predisposing risk factors. They may occur at any point in the vasculature from the aortic root to distal peripheral vessels, but they are most common in the abdominal aorta. Many times they are asymptomatic and undiagnosed, but as they progressively enlarge, they may compress on surrounding structures, release atherosclerotic debris or thrombi and possibly rupture. Aneurysms occur in approximately 3% of people older than 50; some of these do not rupture. An aneurysm is not typically painful until it dissects or ruptures. [table: see text] The abdominal aorta splits at the level of the umbilicus, so the abdomen must be palpated above the level of the umbilicus to feel for aortic enlargement. Obese patients make detection more difficult, as the presence of a pulsatile mass may be covered. An aneurysm will still conduct blood flow into the lower extremities, so pulses will not be compromised, and capillary refill and temperature will be normal. An acute rupture is a catastrophic event characterized by poor perfusion or frank shock and pain in the abdomen, back or groin. Accompanying symptoms may include a pulsatile abdominal mass, absence of distal pulses, and radiating pain into the lower back that is often described as "tearing" or "ripping." The risk of rupture has a direct correlation with an aneurysm's size. Generally, elective surgery is considered with an abdominal aneurysm larger than 4.5 centimeters, but there are many factors which may preclude repair. Non-surgical treatment of an aneurysm has been performed by percutaneously placing a prosthetic graft at the site, anchoring the graft above and below the aneurysm, thereby isolating the aneurysm from the circulation. Surgical treatment for elective repair of an aneurysm that is not ruptured is still very difficult and has a significant risk of complications. A ruptured abdominal aortic aneurysm has a very high incidence of mortality. Early identification and rapid transport to a facility with vascular surgery services are the keys to survival. This case demonstrates early recognition by the EMS crew and successful resuscitation from a cardiac arrest due to profound shock. In other cases, EMS providers may have the first and only opportunity to recognize a ruptured aneurysm and direct the ED and surgical teams to the cause of sudden shock or cardiac arrest.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

This was a great save. The crew could easily have missed the presentation of anaphylaxis and let the window for treatment with epinephrine slip away. This patient was in anaphylactic shock. There were no signs that supported a traumatic injury, and that, combined with diaphoresis, urticaria and tachycardic central pulse, contributed to the suspicion of anaphylaxis. Anaphylaxis is classified as distributive shock. This type of shock is caused by profound systemic vasodilation, and the heart is unable to increase output enough to maintain blood pressure. Other causes of distributive shock include sepsis and spinal cord injury. It is rare to have both hypotension and wheezing in such cases. In an anaphylactic reaction, an allergen, such as a food protein, medication, insect venom or latex, is introduced into the body. The mast cells of the immune system have a protein on their surface called IgE antibodies (Immunoglobulin E). The mast cells are filled with histamines [table: see text] and leukotrienes, which are chemical mediators. These are released when the allergen reacts with the IgE antibodies. When these mediators are released, they cause smooth-muscle constriction in the respiratory and gastrointestinal tracts, resulting in wheezing, stridor, nausea, vomiting and diarrhea. They also cause vascular dilation, leading to edema and urticaria. Most patients will present with either profound vascular effect (shock) or wheezing; this is a rather rare presentation of a patient having both. The medication best suited to counteract the effects of these medicators is epinephrine. Epinephrine is an alpha- and beta-agonist, acting to constrict the vasculature and dilate the smooth muscles in the bronchial tree. Antihistamines can alleviate symptoms of anaphylaxis, but should only be used in addition to epinephrine, not as a substitute. In life-threatening reactions, epinephrine must be given quickly and in a form that the body can distribute. Use of the subcutaneous route with a solution mixed at 1:1,000 dilution is appropriate in most patients, but if the patient is in profound shock and not perfusing the skin (pale, cold, clammy skin), then a more diluted concentration must be given i.v. at a slow rate (1 cc every minute of the 1:1,000 dilution) until the patient recovers. If i.v. access is delayed or not available, give the 1:1,000 dilution intramuscularly, in the tongue or down the endotracheal tube. Refer to your local protocols for dosage, but the usual dose of epinephrine is 0.3-0.5 mg, or 0.01 mg/kg in a child. There are more than 40 million people in the U.S. with allergic histories that place them at risk for developing anaphylaxis. Each year over 5,000 deaths are attributed to anaphylaxis. The risk of death from anaphylaxis increases with a more rapid onset of signs and symptoms. Up to 25% of patients will experience a biphasic reaction. This means there is a recurrence of symptoms several hours after the initial reaction, and it is prudent to observe patients for a period of time following their initial treatment.

Asunto(s)

RESUMEN

The patient with a decreased level of consciousness in the absence of trauma presents difficult assessment and intervention problems. This is compounded when the history is vague or nonspecific. In this case, the patient's history of embolic CVA alerted providers to the possibility of another thrombus. This patient's sudden symptoms could have resulted from a clot in the brain, heart or aorta. This patient presented with an altered level of consciousness, vomiting and low blood pressure. As is typical in elderly female patients, she had an unusual presentation of an MI. A myocardial infaction is classified as either transmural or subendocardial. A transmural infarct extends through the full thickness of the myocardium and holds greater-risk of complications due to loss of functional muscle. In a subendocardial infarct, necrosis is limited to the endocardial surface. Although many elderly patients present with subendocardial MIs, this one had a large transmural MI. In general, the circumflex artery serves the lateral and posterior walls of the myocardium, and the right coronary artery (RCA) serves the inferior wall. In an anterior MI, the left anterior descending artery (LAD) is obstructed. This vessel serves the left ventricle, parts, of the septum and paillary muscles. The LAD is often referred to as the "widowmaker" because left ventricular infarcts have a high incidence of mortality. Occlusion of LAD can cause the usual damage of an MI, and can also cause fatal damage to the valves. This patient was in profound cardiogenic shock -- the left ventricle had infarcted and was unable to maintain cardiac output. Because of her recent stroke, she was not a candidate for thrombolytic medication. With ultrasonography, a large area of the anterior wall was found to be akinetic, or not functioning at all. In this care, the sourrounding myocardium not only has to pump blood with less muscle but also to "drag" the dead tissue. This results in a progressively higher rate of O2 cnsumption within the heart, further damage to the strained heart, and death. As cigarette smoking and obesity complete for the leading preventable cause of death in the United States, familiarity with cardiac anatomy and physiology 12-lead interpretation, pharmacology and electrical therapy is essential for all emergency providers

Asunto(s)

RESUMEN

The patient who presents with a serious head injury is often very difficult to manage. The airways is of primary concern; adequate ventilation must be provided and aspiration protected against. Recent studies suggest that hyperventilation may be as beneficial as was earlier believed. As the pCO2 level decreases, vasoconstriction occurs. If the level falls too low, cerebral perfusion is restricted, and profound cerebral anoxia may ensue. Current standards call for a ventilatory rate to allow for moderate respiratory alkalosis, in theory to mildly constrict teh vessels but still provide adequate perfusion. Arterial blood gas analysis in the ED is the definitive measurement of airway management in the field. Remember that the anatomy of the meningeal layers places the arteries primarily in the epidural space and the veins in the subdural space. A bleed in the epidural space often presents with a rapid onset of signs and symptoms, as was obvious in this traumatized patient. When a bleed occurs in the subdural space, the onset is usually more insidious, and an accurate history is a key to field diagnosis. As the hemorrhage expands, compression displaces the brain within the cranial vault. This displacement causes pressure to be exerted on the medulla of the brainstem. Cushing's Traid is a result of this pressure on the medulla and is evidence by the pulse slowing while systolic blood pressure rises and respirations become ataxic. Vomiting is often associated, and as the bleed continues, herniation syndrome begins. Decorticate posturing is displayed, followed by decerebrate posturing if relief is not provided. It is important to distinguish between decorticate and decerebrate posturing. It is important to distinguish between decorticate and decerebrate posturing. An easy way to remember the differences is to picture the anatomy of the brain. The cerebral cortex lies above the cerebellum, so when a patient's arms flexed up toward the face , he is pointing to his "core" (de-cor-ticate). As the arms extend downward, he is pointing to his cerebellum(de-cere-brate). T o manage the head-injured patient, it is imperative to anticipate potential developments, as well as protect against underlying injuries that may not be fully evaluated until arrival at the ED. Cervical spine often accompany head injuries, and full spinal immobilization is a mandatory precaution in all presentations. With the expanding hematoma found on this patient's neck, vascular damage ws obvious and contributed to the suspicion of spinal injury. As the intracranial pressure rise, vomiting and seizures are common. Placement of an endotracheal tube and having suction equipment ready are the best tools to prevent against aspiration. It is possible to angle the long spine board 10-15 degrees, exercising caution to ensure the patient's spinal alignment is not manipulated during the process. Seizures are usually treated with anticonvulsants like Valium. When a seizure accompanies a head injury, it is a direct result of the increased intracranial pressure and has a generally poor response to Valium, as the underlying cause of the seizure still exists. In this case, the patient had a full neuromuscular blockade, and any seizure would not have been recognized as long as the paralytics were on board. Early notification to the ED is essential, reporting all findings and interventions. This can alert them and give them the opportunity to prepare specialized equipment, such as CT scanners, mechanical ventilators, etc. Also, consider transportation options and the length of time to definitive care, including neurosurgical evaluation. This patient needs to be seen in a trauma center capable of the most thorough evaluation and management. Evacuation by air ambulance may be the most appropriate method of transport.

Asunto(s)