Hot Seat #220: High-Risk Blue or High-Risk BRUE?
Posted on: December 10, 2023, by : Brandon Ho
Case by Richmond Castillo, CNH PEM Fellow
A 14 day old ex-35 weeker M was in his usual state of health until today at 1pm. He was sleeping and suddenly started crying and turned purple. Parents also reported he was cold, limp, and stopped breathing for a short time (parents unsure how long) and then took slow breaths. They felt like it took him about 5 minutes to come back to his usual self. Denied any unusual movements. No previous similar episodes. No rhinorrhea, vomiting, diarrhea, or difficulty drinking. Has been making his usual number of wet diapers and has had no feeding difficulties.
PMHx: Born preterm due to maternal c/f fever and persistent maternal and fetal tachycardia. Admitted to NICU for 10 days for respiratory distress requiring CPAP. Underwent sepsis ruleout and received ampicillin/gentamycin for 36 hours. The rest of his NICU stay was unremarkable. No maternal risk factors for HSV.
PSHx: None
Medications: multivitamin
Feeds: Similac Neosure, 2 oz every 2 hours. Mixing appropriately.
Allergies: None
Immunizations: UTD
Development: No concerns
Family Hx: No family history
Social Hx: Lives with mom and dad
Review of Systems
CONSTITUTIONAL: No fevers, chills, sweats, or decreased PO intake
EYES: No eye redness or discharge
EARS, NOSE, AND THROAT: No rhinorrhea or drooling
CARDIOVASCULAR: No cyanosis of the extremities
RESPIRATORY: No nasal flaring, retractions, episodes of apnea, or increased work of breathing
GI: No vomiting, diarrhea, constipation
NEUROLOGIC: No abnormal movements or shaking
DERMATOLOGIC: No rashes or skin changes.
Physical Exam:
T: 37 °C (Rectal) HR: 147 RR: 41 BP: 86/47 SpO2: 100% WT: 3.05 kg
General: Resting comfortably on bed, in no acute distress
HEENT: Anterior fontanelle open, soft and flat. Atraumatic, normocephalic. No cephalohematoma. Eyes: PEERL. Bilateral nevus simplex over eyes and one on glabella. Ears: normal position and appearance. Nose: nares patent and clear. Mouth: palate intact, moist mucous membranes, with good suck.
Neck: Supple
CV: symmetric, regular rate and rhythm, no murmur. Femoral pulses present
Respiratory: Lungs clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-tender, non-distended, no masses, normal bowel sounds.
GU: normal circumcised genitalia
Skin: Normal, no rashes, no bruises
Musculoskeletal: hips stable with no clicks, moving all extremities equally. Negative Ortolani and Barlow
Neuro: Normal muscle tone, normal suck, normal grasp, symmetric Moro
Results came back with normal POC glucose. WBC 11.0, Hb 11.8, Plt 472. Normal CMP. Normal UA. Normal CRP and Procal. LP notable for being cloudy, CSF Protein 201, CSF RBC of 53, No CSF WBC.
NICU said patient is appropriate for floor. Hospitalist team accepts patient.
Head US is great in neonates and premies with an open fontanelle to assess intraventricular bleeding. However, they will miss subdural and intraparenchymal bleeding associated with NAT. For NAT, in my mind, head CT is far superior.