Hot Seat #172: A Case of a Broken Heart?

Posted on: May 20, 2021, by :

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

Immunizations: UTD

Surgical history: ASD repair, G-tube placement

Family history: No relevant heritable conditions.

Social history: Lives with family. No known sick contacts

Physical Examination

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.

Neck: Supple

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.

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2 thoughts on “Hot Seat #172: A Case of a Broken Heart?

  1. Is that baclofen given orally or does she have a pump? This is just so acute onset that it makes you think tox .

  2. This case centers around a concerning symptom in a medically complex patient who appears otherwise well. Given history of multiple medication use, without recent history of illness, it is reasonable to consider medications as the etiology for her bradycardia -> as medication use could lead to electrolyte abnormalities and/or intoxication/withdrawal.
    The crux of this presentation is the acute change in mental status and findings on physical exam leading to concern for intoxication confirmed by response to Narcan. The disposition hinges on the assessing the cause and length of the intoxication which would best be discussed with a specialist.

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