Case Presentation #2:

“Fussy Infant”

Case Presentation #2: “Fussy Infant”

1

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”

Case Presentation #2: “Fussy Infant”

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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”

Case Presentation #2: “Fussy Infant”

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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?

ST SVT VT

Rate <220 bpm infants >220 bpm infants 120-200 bpm

infants

Complex Narrow (<0.08 sec) Narrow (<0.08 sec) Wide (>0.08 sec)

P waves Present Absent 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”

Case Presentation #2: “Fussy Infant”

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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.