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.
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Case Presentation #2: “Fussy Infant” · Case Presentation #2: “Fussy Infant” Case Presentation #2: “Fussy Infant” 3 Key Question With a heart rate of 218-222, what is
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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”
2
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”
3
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