Download Case Presentation #2: “Fussy Infant”

Case Presentation #2:
“Fussy Infant”
Case Presentation #2: “Fussy Infant”
Presented by Susan Fuchs, MD
A three-week-old female is brought to the ED for vomiting and fussiness. On
examination, she is fussy, has perioral cyanosis, and is mottled.
Begin discussion of assessment and management of this patient.
The PAT is as follows
• Appearance: Infant is fussy, but consolable.
• Work of Breathing: There are mild subcostal retractions.
• Circulation to the Skin: There is perioral cyanosis and mottled extremities.
Vital Signs Include
• Heart rate: 222 bpm
• Respiratory rate: 36 breaths/min
• Blood pressure: 83/58 mmHg
• Temperature: 36.3°C
• Weight: 3.5 kg
Initial Assessment
• A: Airway is patent; there is no nasal congestion.
• B: Lungs are clear bilaterally, but there are mild subcostal retractions, and pulse
oximeter reads 95% on room air.
• C: Heart rate is rapid, there is perioral cyanosis, the extremities are mottled, and
capillary refill is 3 seconds.
• D: Pupils equally reactive.
• E: No evidence of trauma.
Focused History
• S: 10 hours of decreased activity, lethargy, followed by vomiting after feedings
and fussiness.
• A: None.
• M: None.
• P: Has a history of an abnormal pulmonic valve with some stenosis and pulmonic
valve regurgitation diagnosed by prenatal echocardiogram.
• L: Vomited after last feed, approximately 2 hours ago.
• E: Was in NICU for 2 weeks after birth.
Case Presentation #2: “Fussy Infant”
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Case Presentation #2:
“Fussy Infant”
Detailed Physical Exam
• Skin: Mottled extremities with poor perfusion to hands and feet.
• Head: Anterior fontanelle flat, nose has no discharge and is not congested, and
mouth is moist.
• Chest: Rapid heart rate, no murmurs heard, and lungs clear.
• Abdomen: Soft, liver edge palpable, spleen not palpable.
• Neurologic examination: Awake, not lethargic, cries and moves all extremities
with examination.
Key Questions
What is your general impression of this patient?
Characterize the patient’s condition as one of the following:
• Stable
• Respiratory Distress
• Respiratory Failure
• Shock
• Primary CNS/Metabolic Dysfunction
• Cardiopulmonary Failure/Arrest
Core Knowledge Points – General Impression
• This patient is in compensated shock. Her heart rate is very fast, resulting in poor
peripheral perfusion and delayed capillary refill; yet her blood pressure is within a
normal range.
• She has mild retractions, but her respiratory rate is also within a normal range.
Key Questions
What are your initial management priorities?
• Provide oxygen 100% by non-rebreather mask.
• Place on cardiac monitor.
Case Development
• After applying oxygen, her perioral cyanosis improves, and pulse oximeter
improves to 100%.
• Cardiac monitor shows wide complex tachycardia and the rate is 218.
Case Presentation #2: “Fussy Infant”
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Case Presentation #2:
“Fussy Infant”
Key Question
With a heart rate of 218-222, what is the likely arrhythmia?
• With the history of fussiness, and only two episodes of emesis, supraventricular
tachycardia (SVT) is most likely but the QRS complexes show a wide (>120ms)
complex. The rate around 220 would fit supraventricular tachycardia and the lack
of a history of volume loss makes sinus tachycardia unlikely. The concern then is
whether this dysrhthymia represents ventricular tachycardia (VT) or a junctional
rhythm that makes it look like VT?
Case Development
• Repeat vital signs: HR 220 bpm, Respiratory rate 40 breaths/min, BP 83/60
mmHg, pulse oximeter 100% on 15 L oxygen by non-rebreather mask.
Key Question
How could we differentiate between the possible supraventicular with aberrancy or
ventricular dysrhythmias? How do we treat the patient?
Rate
ST
<220 bpm infants
SVT
>220 bpm infants
Complex
P waves
Narrow (<0.08 sec)
Present
Narrow (<0.08 sec)
Absent
•
•
•
•
VT
120-200 bpm
infants
Wide (>0.08 sec)
Absent
At this point the patient is critically ill, but her blood pressure is stable, so there
are several ways to differentiate the arrhythmia; some of which are also possible
treatments.
If intravenous access can be obtained, adenosine 0.1 mg/kg can be administered
while watching the cardiac monitor to assess for and treat SVT. If the child is in
SVT, the rhythm may convert to a normal sinus rhythm (after the brief period of
bradycardia typical of adenosine therapy). If the child is in a junctional
tachycardia, the adenosine may slow the heart down enough to see the junctional
pattern without p waves. Finally, if the child is in ventricular tachycardia, the
heart rate is unlikely to respond with adenosine therapy.
Once the origin of the rhythm can be determined, and if is it truly ventricular
tachycardia, an antiarrhythmic such as amiodarone (5 mg/kg over 20-60 minutes)
or procainamide (15 mg/kg over 30-60 minutes) should be administered via IV
(Do not give both amiodarone and procainamide simultaneously).
If IV access cannot be obtained and the infant begins to deteriorate, synchronized
cardioversion (0.5-1 J/kg) is the treatment for both SVT and possible VT with
pulses. Synchronized cardioversion is used rather than defibrillation.
Defibrillation (2 J/kg) is used if the child has no pulse and the rhythm was VT.
Case Presentation #2: “Fussy Infant”
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Case Presentation #2:
“Fussy Infant”
Case Development
• A pad for cardioversion/defibrillation was applied to the infant’s back, while a 12
lead ECG was obtained.
•
•
•
•
•
•
IV access was obtained and bedside glucose was 80 mg/dL.
Adenosine 0.1 mg/kg was administered with no change in heart rate. Adenosine
0.2 mg/kg was given with heart rate slowing to 216 bpm then returning to 231
bpm, still with a wide complex rhythm. The infant’s respiratory rate was 48
breaths/min and the blood pressure was 83/58 mmHg.
A chest radiograph revealed a normal size heart, and clear lung fields, so a bolus
of 10 mL/kg of normal saline was given.
Amiodarone was administered (1 mg/kg over 5 minutes per cardiology request)
with no change in the heart rate.
Due to respiratory fatigue, the infant was electively intubated and transferred to
the PICU. In the PICU the rhythm was confirmed to be VT and the infant was
converted with a higher dose of amiodarone.
The following day she underwent pulmonic valve replacement, and has had no
recurrence of ventricular tachycardia.
References
American Heart Association. 2005 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 12, Pediatric
Advanced Life Support. Circulation, 2005;112 (Suppl IV): IV 167-IV 187.
Case Presentation #2: “Fussy Infant”
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