MORNING REPORT

Caitlin Kaeppler 9/20/2013

Youre on the wards and its the last day of Intern year
6-month-old male who is directly admitted from an outside

hospital for respiratory distress. More sleepy and has decreased appetite for the past few days. No fevers or URI symptoms. Day prior to admission, the family was camping and had been swinging the infant in a tire swing and picked him up and he subsequently had NBNB emesis that was projectile. After this, he seemed very sleepy and developed perioral cyanosis. There was no choking or respiratory distress. He was responding to parents but would fall asleep very easily. Parents drove him to Hospital (about 20 minutes away.) They had to poke him several times to keep him awake during the car ride because he was so sleepy. At the OSH, parents say that his color was much better but he was still acting very sleepy. In the ED, he had de-sats requiring 1 LPM NC O2 and he was admitted.

At the OSH
Parents say that during his admission (~36h), he became

less sleepy but more irritable. He had eaten well overnight, waking up almost every hour to eat. He continued to have emesis. No diarrhea. He remained on supplemental 1L NC O2 overnight but due to lack of improvement in respiratory status the next morning, he was transferred to Primary Childrens Hospital inpatient service for further management.

HPI continued
PMH: Born full term via NSVD without complications. He had

congenital cataracts. No other medical problems. PSH: Cataract surgery 1 month prior to admission Immunizations: Has not yet received his 6 month vaccines but is otherwise up to date. Meds: None Allergies: NKDA Diet: Formula fed and assorted table foods Development: Appropriate for age FH: No history of significant medical problems in childhood. SH: Lives in UT with his parents, no other siblings. There is a cat in the home. No one has been sick at home. The family was camping when his symptoms began.

Review of Systems
GENERAL/CONSTITUTIONAL: Increased in fatigue over the past few days. No fever, change in appetite, change in weight. HEENT: Denies eye redness or irritation. No problems with hearing or ear pain. No epistaxis, runny nose, congestion, sneezing. No mouth sores, sore throat, or problems swallowing. CARDIOVASCULAR: Shortness of breath since admission to OSH. No sweating with feeds, color change with feeds, history of murmur, or fainting. RESPIRATORY: Respiratory distress with desats requiring supplemental oxygen. Perioral cyanosis prior to ED presentation. Denies chronic cough, hemoptysis, history of pneumonia, wheezing, or night sweats. GASTROINTESTINAL: NBNB vomiting. Denies diarrhea, pain with urination, or blood in urine. MUSCULOSKELETAL: Denies joint or muscle pain, neck pain, or recent injuries. HEME: Denies easy bruising or bleeding tendency. SKIN: Denies rashes or new lesions. NEUROLOGIC: Irritability over the past day. Prior to that, he had been lethergic. Denies trauma, LOC, seizure activity, or developmental delays.

Physical Exam
T 37.2. HR 148. RR 44. BP 90/56. SaO2 100% on Room Air. WEIGHT - 7kg, (12%ile) HEIGHT - 66 cm, (21%ile), OFC 16.9 cm (63%ile)

GENERAL: Very fussy and crying during parts of exam, will suddenly become quiet and fall asleep. Well-developed, well-nourished infant. HEAD: Plagiocephaly. Anterior fontanelle is full, no splitting of sutures. EYES: Normal pupillary reflexes bilaterally, extraocular movements intact, conjugate gaze, no conjunctival injection. EARS: Normal external ear exam. TMs normal bilaterally. NOSE: No discharge or obstruction. OROPHARYNX: Moist mucus membranes, no cleft palate, no exudate, no oropharyngeal lesions. NECK: Supple without lymphadenopathy or tenderness to palpation. CARDIOVASCULAR: Tachycardic, regular rhythm, normal S1/S2, without murmur or gallop. 2+ pulses in upper extremities. Distal pulses 1+. Capillary refill time 3-4 seconds. LUNGS: Tachypneic, intermittent increased work of breathing with intercostal and subcostal retractions, breath sounds are clear to auscultation bilaterally, good air flow. No wheezing or stridor ABDOMEN: Soft, non-tender, non-distended with active bowel sounds and no masses. Liver felt 2 cm below RCM. EXTREMITIES: Lower extremities are slightly cool. Upper extremities warm. BACK: No abnormalities noted. GENITOURINARY: Normal Male external genitalia, Tanner stage I. NEUROLOGIC: Fussy and then lethargic. Moves all extremities symmetrically. Normal upper and lower reflexes bilaterally. No clonus. Grossly normal strength when awake. Good head control and truncal support. Legs somewhat hypotonic. SKIN: Slightly mottled extremities and trunk. Nevus simplex on forehead, occiput, and midback. 2-3 small faint erythematous papules on left leg and 1 on right leg that are not blanching.

Differential diagnosis for a 6-month-old male with two days of respiratory distress, altered mental status, emesis, and poor perfusion on exam

Differential Diagnosis:
Respiratory: -Bronchiolitis -Asthma or reactive airway disease -Bacterial pneumonia -Aspiration -Foreign body -Pneumothorax -Pulmonary edema -HAPE CV: -Congenital heart defect -Cardiomyopathy -Myocarditis -Cardiogenic shock -Arrythmia -Pericardial effusion -Pericarditis FEN/GI: -GERD -Dehydration -Gastroenteritis -Ulcers NEURO: -Space-occupying lesion -HACE HEME/ID -Septic shock -Meningitis- bacterial or viral -Viral encephalitis -TORCH infection -Anemia Metabolic -Inborn error of metabolism Other: -Trauma -NAT -Ingestion

Labs and Tests

OSH labs: Tox screen was negative, VRP negative,

electrolytes normal, CXR reportedly normal Initial labs: Blood gas showed pH 7.36, mild metabolic acidosis. Lactate 5. 10 cc/kg NS bolus was started Patient was sent to radiology for a stat head CT, CXR, and KUB Head CT: Unexplained ventricular and extraventricular fluid prominence. KUB normal CXR

Radiology

Radiology

Radiology
Kerley B lines represent interstitial edema in the

pulmonary septa from back-up of flow from left ventricular failure.

Treatment Course
Cardiology was called and the fellow performed a stat

echo at bedside, which showed marked left ventricular dilation and estimated EF 16% Transferred to PICU Approximately 15 minutes after arrival to the PICU, the patient had a PEA arrest. Due to potential reversibility of this process, ECMO was activated. He received 17 doses of epinephrine and 50 minutes of CPR without consistent return of pulses Emergent decompressive atrial septostomy Studies sent: EBV, HSV, CMV, HIV, mycroplasma, toxo, Adenovirus, respiratory viral panel Acyclovir started and IVIG for myocarditis

Dilated Cardiomyopathy
Most common reason for heart transplantation in children

worldwide and the most common cardiomyopathy in children Ventricular dilation may help compensate and maintain cardiac output, so children may remain asymptomatic for many years

Causes
39% Neuromuscular disorders (congenital myopathies and muscular dystrophies) 27% Myocarditis (esp coxsackievirus, adenovirus, enterovirus, influenza, CMV, EBV) 18% Familial isolated cardiomyopathy Other causes: Metabolic (Pompeii disease) Nutritional deficiencies
(carnitine, thiamine, kwashiorkor)

Endocrine disorders
(hypo/hyper-thyroidism)

Drugs (doxorubicin)

Presentation
Predominantly left-sided Cough, dyspnea on exertion, orthopnea Predominantly right-sided Abdominal pain, emesis, anorexia, peripheral edema All patients Nausea, chest pain, diaphoresis, palpitations Physical exam shows tachypnea, rales, increased JVP,

hepatomegaly, peripheral edema

Circulatory shock
In children, CO is more dependent on heart rate than on

stroke volume due to lack of ventricular muscle mass Children maximize SVR to maintain a normal BP, even with significant decreases in CO Therefore, pay most attention to HR and perfusion (cap refill, pulses, UOP, mentation)

Shock
Heart rate
Hypovolemic Septic Distributive Cardiogenic

Pulses/Perfusion

Blood Pressure

References
Pediatrics in Review: Index of Suspicion. Vol 25, No. 3.

March 2004. Madriago, Erin and Michael Silberbach. Heart Failure in Infants and Children. Pediatrics in Review 2010;31;4 McKiernan, Christine A. and Stephen A. Lieberman. Circulatory Shock in Children: An Overview. Pediatrics in Review. 2005;26;451