by Joelle Simpson
This is a 2 week old full-term infant with 3 days congestion and cough x 1 day that you receive on signout. The
provider signing out says that she is concerned because the baby has had
tachypnea to 80s, has a mottled appearance to the skin. The patient appears comfortable otherwise and otherwise has no significant exam findings. A CXR was
unremarkable. The infant has been observed in the ER for 8 hours and has fed
well despite tachypnea.
ROS: Afebrile,
non-fussy, normal po intake, normal number of wet diapers. Emesis x 1 after
feeding 1 day ago. Has 1 prior ED visit at 6 days of life for fussiness
attributed to gas. No known sick contacts.
Birth history:
C-section due to placenta previa. No problems during pregnancy, delivery, or
after birth.
Fam Hx: Father
had recent heart surgery to repair damaged heart valve. Mom reports that her
first child died at 2 months of age. Mom believes the child died because of
mismatch with maternal blood and reports the child stopped eating, had no bowel
movements for 1 week, had no urine output and swollen abdomen. Two other
siblings are well.
Exam:
Vitals T 37.3; HR 154; RR 80; BP 97/65 O2 sat 100%
Alert, tachypnea, and mottled skin
Lungs CTAB with substernal retractions
RRR,
no murmurs, 2+ femoral pulses
Rest of
exam is unremarkable
What do you think?
(click on "comments" below and share your insightful insights)
Hmmm.... is this periodic breathing or has this little one been persistently tachypneic. I'm going with persistently high RR in the 80's - and tin that case, I'm kind of annoyed at the previous provider (PP) who didn't admit the kid already - I mean, really, you're been wathcing them for 8 hours in the ETU breathing this fast the whole time. Really?
ReplyDeleteAlso, did mom get "the shot they give you so the blood type mismatch doesn't happen with this baby?" (which is how I would ask the mom)...
I kind of want an EKG and lytes...
I agree with Sabah in that the disposition for this pt should have been determined much earlier. Highest on my differential would be bronchiolitis and cardiac. I would admit him for risk of apnea if his EKG was normal, regardless if RSV result. I would also have ALTE in the back of my mind given the unusual sibling death and the previous visit for " fussiness". I wouldn't necessarily do a CT scan in the ED, but would communicate with the admitting team to have a low threshold for NAT workup.
ReplyDeleteThis is an interesting case. I suspect the baby looked quite well (except not quite "well enough") for her to have been just observed for 8 hrs already. Highest in my differential would be SBI, viral (RSV, though not the season), metabolic disorder especially with the unexplained sibling death, cardiac (classic age for presentation, may not have murmur on exam, though I'd expect SOME other abnormality such as hepatomegaly or lower sat on a post-ductal reading).
ReplyDeletePretty much all of these require further workup. I would start with bedside glucose, get CBC, BMP vs CMP, UA, cultures, RSV. I'm not sure I'd reflexively order an EKG at this point, as long as a normal sat has been checked somewhere besides the R hand, but would strongly consider it. If none of that returns obviously abnormal in the ED, I would still strongly consider a full septic workup with LP, empiric antibiotics and admission.
So the comment just above is from Emily. I am not sure how to get it to link to my real name, it seems to have linked to a very old blogspot account.
ReplyDeleteInteresting ... there seems to be a fairly wide spectrum of things folks would do to "work this up." This explains why the resident staffing this patient was a bit lost about the "evidence" guiding this patient's management ... If all the tests above return normal -- would you admit for observation as an inpatient, or be satisfied with your period of obs in the ED and discharge this patient home -- despite the abnormal vital signs?? things that make you go hmmmmm....
ReplyDeleteThis is a kid on whom i'd be pretty quick to order an istat gas to see if there was some scary metabolic acidosis that the little guy has been trying to breathe off. If that were reassuring, it would give me time to consider the broad differential as outlined by others (cardiac, infectious, NAT, etc). In addition to the studies, mentioned, this is one for which I would earn my 'PCP callback star' early and figure out exactly what the sibling had died of and any PCP concerns. I would also make sure rads had reviewed the CXR to ensure no subtle abnormalities.
ReplyDeleteTo Joelle's point, even if the studies were normal, I wouldn't be comfortable sending a tachypneic, mottled 2 week old home. I would strongly consider a full sepsis work-up and inpatient admission.
I think it would also be useful to know this patient's birth weight and current weight. You can gauge hydration status and infant's growth parameters, which could be very helpful in this patient.
ReplyDeleteAlways must consider sepsis, cardiac, respiratory issues in this kid.
A blood gas would be useful to detect acid/base status for metabolic defects. Is the infant blowing off CO2 from his profound acidosis? Would also remind everyone that urea cycle defects can give you a respiratory ALKALOSIS...may want to consider an ammonia level! (yay for lovely boards memories)
Agree with Nazreen's comments. The truth is, we'd all order all of those tests because a RR=80 without fever, dehydration, or LRI symptoms is obviously abnormal.
ReplyDeleteI would suggest for the next one of these cases that we pick one test, and one test only.
i would pick an ABG followed by an echo (while telling cards that the other tests are 'pending')
if i had to hedge on what i think this is, i would pick something metabolic (insert esoteric FAO here) or non-cyanotic CHD like total veins with obstruction.
I agree with much of the DDx that has been generated and discussion above. An afebrile 2-week old breathing persistently 80 requires additional work-up and admission. If the RSV is positive, then I might chalk it up to RSV. But if I can't hang my hat on anything, I'd consider further evaluation. In addition to the DDx generated above, we should consider significant anemia (given prior sibling ?history) and HSV in the differential. The CBC will tell us the Hgb, and the LFTs will help r/o (disseminated) HSV sepsis.
ReplyDelete