Hot Seat #37 Denouement: 18 month-old with increased work of breathing

by Jason Woods, Children's National
with Maybelle Kou, Inova Fairfax, on the Hot Seat

The Case

This is a case of an 18 month-old boy with respiratory distress. His initial exam was not unlike many patients we see in the ER in the winter. But after a nebulizer treatment, he became worse clinically. This prompted a chest x-ray showing cardiomegaly. Maybelle, our Hot Seat attending for this case, uses the case to illustrate what novice learners can get from this and also goes through the reasoning behind some of the hard management decision. For the full case presentation, click here.

Here's How You Answered Our Questions
What is your first step in management?
Less than 3 years PEM experience (n = 11)

 

Greater than 3 years PEM experience (n = 9)

The split on this question was between starting this child on albuterol 7.5 mg with atrovent or just albuterol 2.5 mg without atrovent. The less than 3 years PEM experience group was evenly split between the two options, with a smaller fraction going with albuterol 7.5 mg without the atrovent. At this point, this patient's clinical course seems consistent with bronchiolitis. We know that there are no evidence-based therapies that are effective in bronchiolitis in the ER. The debate here seems to be whether you try a single 2.5 mg albuterol (as allowed for in the 2006 AAP bronchiolitis guidelines) or consider this more like asthma since this 18 month-od child has had multiple episodes of respiratory distress and is on budesonide. Those with greater than 3 years of PEM experience seem to side more with the "treat like asthma" camp. One person in the greater than 3 years PEM experience group pointed out that he or she would start with oxygen rather than any of these aerosolized therapies. Of note, this patient's oxygen saturation was 98% on room air.

Do you order a steroid with your initial therapy?
Less than 3 years PEM experience (n = 10)

Greater than 3 years PEM experience (n = 7)

The response numbers here are small but based on responses, both groups are similarly split on giving this child steroids. Most would not give steroids, although the numbers are relatively close. This is interesting given that in the prior question the majority of those with greater than 3 years of PEM experience would give albuterol 7.5 mg and atrovent. In practice does this mean we are treating these bronchiolitis patients with multiple episodes somewhere between bronchiolitis and asthma?

The patient doesn't get better with your initial therapy of albuterol. In fact, the patient seems more tachypneic and poorly perfused with worsening vital signs and 94% on RA. And here is the x-ray you get because of worsening clinical symptoms.

Of the following, what is your next management priority?
Less than 3 years PEM experience (n = 15)

Greater than 3 years PEM experience (n=10)

This x-ray shows cardiomegaly, perhaps explaining the respiratory distress in this patient. More on that later from our Hot Seat commentary and Jason. This question brings up the contentious debate about the role of fluids, diuretics, and inotropy in potential heart failure. In the less than 3 years PEM group, the largest group would start a dopamine drip with the next largest group giving a diuretic. The greater than 3 years PEM group is evenly split between dopamine and a diuretic. Only one person (in the less than 3 years PEM group) would give a normal saline bolus.

Clinical Reasoning
A great thank you to Dave, Paul, and Simon from Australia for your comments. Below is an excerpt of a few clinical reasoning pearls but reading their comments in full is recommended.

"Big red flag on wheezer that this isn't asthma is puffiness/edema. But given the damage is done with the albuterol, what next?" -Paul Mullan, Children's National

"Re-evaluating perfusion is a must for deciding inotropes....need a better sense of central vs. peripheral perfusion. And a little fluid (5-10ml/kg) is important to fill the tank." -Dave Mathison, Children's National

"Figure out quickly if this kid is warm or cold, wet or dry. Exam didn't tell us about warmth/perfusion/cap-refill initially, but second exam said he's "cold" (other cold signs in general are AMS, narrow pulse pressure, thready pulses)." -Paul Mullan, Children's National

"Next, is he wet? - yes (wet signs in general are: edema, crackles, wheezing, cxr pulm edema seen in him I believe with vessel fullness beyond the 2/3 mark laterally, elevated JVP, HSM)." -Paul Mullan, Children's National

"If this is all pericarditis, then you can try to decrease afterload while preparing the child for a pericardial tap/drain. Intubating these kids is bad news because you'll drop the preload amidst tamponade physiology. So i'd have dopamine and a big needle on hand while waiting for a CICU bed/eval." -Dave Mathison, Children's National

"If this is function (myocarditis/cardiomyopathy), then there are fewer life-saving interventions we have as ED docs before the kid crashes. These are the PEM-docs worst nightmares. Inotropic combos like epinephrine/milrinone or epi/dopa are good.....so is good ol' dobutamine. But these are all arrhythmogenic and risky." -Dave Mathison, Children's National

"I wouldn't attempt intubation unless I had central access either with a femoral line or IO." -Dave Mathison, Children's National

"The expression I was taught was "warm them up (improve cardiac output with milrinone as an inotrope/vasodilator) then dry them out (with lasix)." But this kid is circling the drain, will certainly die if you do nothing, and if you haven't heard from cardiology, it's time to get aggressive so you'll probably do both at once."
-Paul Mullan, Children's National

Paul is also sharing with us a pediatric acute heart failure treatment algorithm that was created by the Evidenced-Based Outcomes Center at Texas Children's Hospital. It is downloadable as a PDF. Thank you to Paul and Texas Children's for sharing.

From the Hot Seat
by Maybelle Kou, Inova Fairfax

Wow, Paul and David, you guys are always here first: you must spend all day on the computer.

Since the audience has probably read their responses already let me add a few more things to think about.

Can you imagine a novice level history being given to you here?

My recent enlightenment exercise is to encourage all medical trainees to paint a descriptive picture of the patient; not just a succinct history that includes pertinent positives and negative ROS, but also to communicate a good visual. All folks in an ED should know from the doorway if the child is sick or not sick. Give your trainee this expectation and hopefully it will pay forward and get you into the patient’s room before they crash. Documentation also should contain pertinent negatives. AND DO NOT COMMIT THE ED SIN OF PREMATURE CLOSURE.

Luckily we have direct bedding otherwise I would be concerned that in the middle of cough and cold season, this little one would sit out front for a bit, especially if the child were still bundled up in multiple layers of clothes. As I try to remind trainees as they go into the umpteenth patient with a cough: don’t miss myocarditis in a sea of bronchiolitis. But I can also extrapolate (having trained in general emergency medicine) as to my suspicions of this not being primarily a respiratory illness: decreased urine output, respiratory distress in the setting of swollen eyes could also point to a cardiac or renal process.

Missing details from THE CASE:
1. Blood pressure. I know. It is not a favourite vital sign to obtain. Most screaming children will have one, but for the puffy, fussy toddler with a dry diaper...I want it and I want it now.
2. Skin: Turgor/Cap refill? Can assess in seconds, easy test to do. TOUCH the patient. Are they cool and clammy? Children need to be undressed.
3. Cardiac exam: FEEL for thrills or heaving. Listen for gallops or rubs (not mentioned here but in the spirit of what seems to be a sick kid with resp distress….)
3. Neuro: “grossly normal for age”. Sounds like an EMR clickbox. Again, I encourage learners to describe the passive neuro exam. If the child is sitting limply in mom’s lap breathing at 62 (vs fighting every device known to man while sucking voraciously on a pacifier,) there is a problem.

Initial assessment: Respiratory distress with VS concerning me for imminent respiratory failure BUT WITHOUT A BLOOD PRESSURE I CAN’T SAY DEFINITIVELY THEY ARE IN SHOCK.
DDX: Bronchiolitis, pneumonia, cardiac: myocarditis with or without effusion, unknown CHD, renal disease, sepsis, hypothyroidism.
Management: Move ASAP to a resuscitation room, just in case.
A: Consider hi-flow nasal cannula to titrate for sats above 95%. Consider Bi-Pap if you have it.
B: One can attempt a breathing treatment here (as is done with many adults with “cardiogenic” asthma) but one needs to be wary of the sympathomimetic effects that can occur. More strain, less gain. (While we’re in the RAD territory, in a child with steroid dependent asthma, one could argue that the reason to give a steroid here is more for stress dosing although I am sure this might be controversial).
C: Establish IV access: i-stat lytes (glucose and potassium), as well as VBG. IO if you can’t get venous. TSH and free T4 as well as cardiac panel including troponin.
Fluids: controversial if you suspect congestive heart failure but if the patient is in shock, treat with a 5-10 cc/kg bolus.
Bedside ultrasound to assess size, ventricular function and rule out effusion and tamponade. EKG to rule out ischemic changes.

When the XR comes back (if you are not blessed with an ultrasound) with a heart the size of a football, confirming your suspicion of cardiogenic shock, I hope you have already called your PICU team/prepared transport.

Pressor considerations:
Depends on what you have at your place. If you are in a community ED and need to transfer, remember dobutamine is not a bad choice and readily available unless pt is crashing and you need EPI. Don’t be afraid to IO but do use local anesthetic if possible. As Paul and David mentioned, this is the sort of patient to optimize cardiac output BEFORE attempting intubation, and you also need to be careful about meds. Adjunct airway and difficult airway algorithms apply. Non-invasive positive pressure ventilation would be really great here as long as the patient is not too far gone.

The Denouement
by Jason Woods, Children's National

Please note that the progression of illness in this case was changed to facilitate the Hot Seat discussion. The actual patient never deteriorated and in the ED remained only tachypneic. 

In the ER at presentation, based on her reported history, this patient was initially treated with a single 2.5 mg albuterol neb. She was not given steroids due to the lack on convincing clinical features (very soft symptoms of URI, no definitive wheeze, no other personal or familial atopic history). The eyelid swelling that the mother described was not present in the ED. A chest x-ray was not pursued initially as she had no crackles, no murmur, no focality to exam, and had normal pulses. She was not responsive to albuterol and on further questioning the mother reported that for several days her urine output had been decreasing. Chest X-ray showed dramatic cardiomegaly. Once this was obtained the mother then reported (after initially denying any family history) that the patient had a half-brother with left ventricular non-compaction and a maternal history of idiopathic myocarditis in childhood. EKG showed only sinus tachycardia but no ventriculomegaly. Echo showed significant dilation of both the LV and RV, with severely decreased LV function, mitral regurgitation, and LA dilation. Based on poor LV movement and echo appearance she was diagnosed with LV non-compaction.

Interestingly NEITHER the consulting cardiology fellow or the CICU attending heard crackles or murmurs, or felt abnormal pulses on initial exam. These were variably documented at later times. The patient spent 18 days in the CICU but did not require any significant procedures and was discharged home on diuretics, Lisinopril, and Carvedilol. She has been referred to Genetics and has tolerated outpatient management for several months.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here. The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.