Hot Seat #172: A Case of a Broken Heart?Posted on: May 20, 2021, by : Chisom Agbim
HPI: A 12-month-old girl with cerebral palsy, chronic lung disease, and G-tube dependence is brought in by ambulance for bradycardia. Her caregiver states that she had an episode of bradycardia on her home monitor with HR 50s. Her usual baseline is heart rate of 100 to 130s This lasted about 1 minute. During the episode, she was mentating appropriately and was warm and well-perfused. She seemed sleepier after the episode but is now back at her neurological baseline. However, her heart rate is still in 70-80s. She has not had any fevers, changes in medications, sick contacts or changes to her G-tube feeds.
Review of Systems
Constitutional symptoms: Tolerating G-tube feeds, denies fever, fatigue
Skin symptoms: denies rash, denies pruritus.
Eye symptoms: denies pain, denies discharge.
ENMT symptoms: denies sore throat, denies nasal congestion.
Respiratory symptoms: denies shortness of breath, denies cough.
Cardiovascular symptoms: Bradycardia
Gastrointestinal symptoms: no abdominal pain, no vomiting, no nausea, no diarrhea.
Genitourinary symptoms: no dysuria, no hematuria.
Musculoskeletal symptoms: no back pain, no muscle pain, no joint pain.
Neurologic symptoms: no seizure, no altered level of consciousness.
Hematologic/Lymphatic symptoms: no swollen nodes.
Allergy/immunologic symptoms: no recurrent infections, no impaired immunity.
Medications: Bosenten, Baclofen, Bumetanide, erythromycin, famotidine, HCTZ/Spironolactone, levalbuterol, fluticasone (inhaled), potassium chloride, assorted elemental minerals (calcium, iron, magnesium).
Allergies: No Known Allergies
Surgical history: ASD repair, G-tube placement
Family history: No relevant heritable conditions.
Social history: Lives with family. No known sick contacts
Temp: 36.5C, HR 78, RR 26 , BP 82/50 , SpO2 100 % on RA
General: Alert, interacting, playful
Skin: Warm. dry. pink.
Head: Normocephalic. Atraumatic.
Eye: PEERLA, EOMI. Normal conjunctiva.
ENMT: TMs clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: No murmur. No gallop. Extremity pulses equal. Capillary refill: < 2 seconds. Bradycardic to 77, normal rhythm.
Respiratory: Lungs CTAB. Respirations are non-labored. Breath sounds are equal.
Gastrointestinal: Soft. Non-tender. Non-distended. Normal bowel sounds. No organomegaly.
Musculoskeletal: Normal ROM. Normal strength.
Neurological: Alert. No focal neurological deficit observed.
Lymphatics: No lymphadenopathy
You decide to order a CBC, Utox, BMP, magnesium and phosphorus level as well as an EKG and chest x-ray. An EKG shows sinus bradycardia with sinus arrhythmia and a ventricular rate of 80 bmp. While your labs are pending, your patient is sent for a chest x-ray. While patient was in the radiology suite for x-ray she is noted to be obtunded and responsive only to sternal rub. She is rushed back to her ED room and you note that she has pinpoint pupils. She is bradycardic with HR 50s and otherwise hemodynamically stable and well perfused. Her abdomen soft, non-tender non-distended.
You assist the patient’s ventilation with BVM and administer Narcan x 1. You observe some improvement with increased pupil size of 2mm and reactive and increased energy level and responsiveness to light stimulation following the Narcan dose. You send the patient for a stat Head CT which shows no acute changes from previous studies.
Cardiology is consulted and a bedside echocardiogram shows no changes and good function. The patient’s CBC, BMP, magnesium, phosphorus and Utox return normal. She remains hemodynamically stable with a HR 77.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
- Hot Seat #172: A Case of a Broken Heart? - May 20, 2021
- Hot Seat #163: 3 year old female with constipation - January 14, 2021
- Hot Seat #152: 12 month-old with altered mental status - May 22, 2020